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DRUG MARKET TRENDS: CANNABIS OPIOIDS © United Nations, June 2021

DRUG MARKET TRENDS: CANNABIS OPIOIDS © United Nations, June 2021

DRUG MARKET TRENDS: © , June 2021. All rights reserved worldwide. ISBN: 9789211483611

WORLD REPORT 2021 REPORT DRUG WORLD eISBN: 9789210058032 United Nations publication, Sales No. E.21.XI.8

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Division for Analysis and Public Affairs United Nations Office on Drugs and Crime PO Box 500 1400 Vienna Austria Tel: (+43) 1 26060 0 Fax: (+43) 1 26060 5827

E-mail: [email protected] 2 Website: www.unodc.org/unodc/en/data-and-analysis/wdr2021.html PREFACE 3

Drugs cost lives. unemployment and inequalities, as the world lost 114 million jobs in 2020. In doing, so it has created conditions that leave In an age when the speed of information can often outstrip more people susceptible to drug use and to engaging in illicit the speed of verification, the COVID-19 has taught crop cultivation. us that it is crucial to cut through the noise and focus on facts, a lesson that we must heed in order to protect societies from Furthermore, disparities in access to essential controlled med- the impact of drugs. icines around the world continue to deny relief to patients in severe . In 2019, four standard doses of controlled pain Drug use killed almost half a million people in 2019, while drug were available every day for every one million inhab- use disorders resulted in 18 million years of healthy life lost, itants in West and Central Africa, in comparison to 32,000 mostly due to opioids. Serious and often lethal illnesses are doses in . more common among drug users, particularly those who inject drugs, many of whom are living with HIV and . In parallel, drug traffickers have quickly recovered from the Preface OPIOIDS | CANNABIS, initial setback caused by lockdown restrictions and are oper- The illicit drug trade also continues to hold back economic and ating at pre-pandemic levels once again. Access to drugs has social development, while disproportionately impacting the also become simpler than ever with online sales, and major most vulnerable and marginalized, and it constitutes a fun- drug markets on the dark web are now worth some $315 mil- damental threat to security and stability in some parts of the lion annually. Contactless drug transactions, such as through world. the mail, are also on the rise, a trend possibly accelerated by Despite the proven dangers, drug use persists and, in some the pandemic. contexts, proliferates. Over the past year, around 275 million Communicating facts about drugs and promoting science-based people have used drugs, up by 22 per cent from 2010. By 2030, interventions is an absolute necessity if we are to reduce demographic factors project the number of people using drugs demand and supply of drugs, while also facilitating access to to rise by 11 per cent around the world, and as much as 40 per controlled for those in need. It is also the surest path cent in Africa alone. to eliminating stigmatization and discrimination and providing There is often a substantial disconnect between real risks and adequate treatment, as seven in eight people who suffer from public . In some parts of the world for example, can- drug use disorders remain without appropriate care. nabis products have almost quadrupled in , and yet the At the UN Office on Drugs and Crime we are dedicated to pursu- percentage of adolescents who perceive cannabis as harmful ing and promoting fact-driven, human rights-based approaches has dropped by as much as 40 per cent, despite the evidence to drug control and treatment. linking regular use to health problems, particularly in young people, and despite the correlation between potency and harm. I am proud to present to you this World Drug Report, which embodies our commitment to raising awareness and combat- New psychoactive substances also continue to be a challenge, as ing misinformation. markets witness the introduction of new drugs that are unpre- dictable and poorly understood. Regulatory and legislative It is my hope that this report will inform policymakers, practi- steps have been successful in stemming the tide globally, but tioners, and the general public on the facts of the world drug in low-income countries the problem is on the rise; between problem, and provide them with a powerful tool to share evi- 2015 and 2019, South and Central America recorded a fivefold dence and information, and in doing so help save and preserve rise in the amount of new synthetic psychoactive substances lives. seized, while in Africa increased from minor to sub- stantial amounts. Strong increases were also reported in South and Southwest Asia as well as the Near and Middle East. Meanwhile, the COVID-19 crisis has pushed more than 100 Ghada Waly, Executive Director million people into extreme poverty, and has greatly exacerbated United Nations Office on Drugs and Crime 3 WORLD DRUG REPORT 2021

EXECUTIVE SUMMARY POLICY IMPLICATIONS BOOKLET

GLOBAL OVERVIEW OF DRUG DEMAND AND DRUG SUPPLY BOOKLET

DRUG MARKET TRENDS: CANNABIS, OPIOIDS BOOKLET

DRUG MARKET TRENDS: , -TYPE BOOKLET

COVID-19 AND DRUGS: IMPACT AND OUTLOOK BOOKLET CONTENTS 3

PREFACE 3 EXPLANATORY NOTES 7 SCOPE OF THE BOOKLET 9 CANNABIS 11 Cannabis supply 11 Cannabis use 19 Developments in measures regulating the non-medical use of cannabis 31 CANNABIS, OPIOIDS | Contents OPIOIDS | CANNABIS, OPIOIDS 57 Overlap between the use of opioids 57 Demand for opioids 65 Access to pharmaceutical opioids for 79 Supply of 85 Supply of other opioids 97

ANNEX 105 GLOSSARY 121 REGIONAL GROUPINGS 123

5 Acknowledgements The World Drug Report 2021 was prepared by the Research and Trend Analysis Branch, Division for and Public Affairs, United Nations Office on Drugs and Crime (UNODC), under the supervision of Jean-Luc Lemahieu, Director of the Division, and Angela Me, Chief of the Research and Trend Analysis Branch, and the coordination of Chloé Carpentier, Chief of the Drug Research Section.

Content overview Mapping Chloé Carpentier Antero Keskinen Angela Me Francesca Massanello Irina Tsoy WORLD DRUG REPORT 2021 REPORT DRUG WORLD Analysis and drafting Kamran Niaz Editing Thomas Pietschmann Jonathan Gibbons

Data management and estimate Graphic design and production production Anja Korenblik Enrico Bisogno Suzanne Kunnen Diana Camerini Kristina Kuttnig Hernan Epstein Maria Moser Natalia Ivanova Lorenz Perszyk Andrea Oterová Umidjon Rakhmonberdiev Data support Francesca Rosa Natalia Ivanova Ali Saadeddin Administrative support Andrada-Maria Filip Iulia Lazar Review and comments

The World Drug Report 2021 benefited from the expertise of and invaluable contributions from UNODC colleagues in all divisions and from the INCB .

The Research and Trend Analysis Branch acknowledges the invaluable contributions and advice provided by the World Drug Report Scientific Advisory Committee: Jonathan Caulkins Afarin Rahimi-Movaghar Paul Griffiths Peter Reuter Marya Hynes Alison Ritter Vicknasingam B. Kasinather Francisco Thoumi Charles Parry

The analysis on access to pharmaceutical opioids in Booklet 3 is based on original data graciously shared by the 6 INCB Secretariat. EXPLANATORY NOTES 3

The designations employed and the presentation of The following abbreviations have been used in the the material in the World Drug Report do not imply the present booklet: expression of any opinion whatsoever on the part of the Secretariat of the United Nations concerning the legal -PVP alpha-pyrrolidinovalerophenone status of any country, territory, city or area, or of its CBD authorities, or concerning the delimitation of its frontiers or boundaries. COVID-19 coronavirus

Countries and areas are referred to by the names that DALYs disability-adjusted life years were in official use at the time the relevant data were Δ-9-THC delta-9- collected. ECOWAS Economic Community of West African States Since there is some scientific and legal ambiguity about the distinctions between “drug use”, “drug misuse” and EMCDDA European Centre for Drugs and “drug abuse”, the neutral term “drug use” is used in the Drug World Drug Report. The term “misuse” is used only to Europol Agency for notes Explanatory OPIOIDS | CANNABIS, denote the non-medical use of prescription drugs. Enforcement Cooperation All uses of the word “drug” and the term “drug use” in ha hectares the World Drug Report refer to substances controlled INCB International Control Board under the international drug control conventions, and their non-medical use. NPS new psychoactive substances

All analysis contained in the World Drug Report is based S-DDD defined daily doses for statistical purposes on the official data submitted by Member States to the UNODC United Nations Office on Drugs and Crime UNODC through the annual report questionnaire unless indicated otherwise. WHO World Health Organization

The data on population used in the World Drug Report are taken from: World Population Prospects: The 2019 Revision (United Nations, Department of Economic and Social Affairs, Population Division).

References to dollars ($) are to dollars, unless otherwise stated.

References to tons are to metric tons, unless otherwise stated.

7

SCOPE OF THE BOOKLET 3

Constituting the third part of the World Drug Report 2021, With respect to opioids, the booklet discusses the over- the present booklet contains an analysis of the global laps between the various opioids, mostly in terms of market for cannabis, starting with a review of cannabis demand dynamics. It also contains the latest estimates of supply, including trends in the cultivation of and traffick- and trends in use at the global and regional levels, ing in cannabis and cannabis at the global level including an update on the availability of pharmaceuti- and in the various regions. It contains the latest estimates cal opioids for medical consumption. That is followed by of and trends in cannabis use, including an analysis of an overview of the latest estimates of and trends in the changes over time in cannabis use and risk . supply of opiates, from the cultivation of The booklet also includes an overview of the latest devel- and production of opium to trafficking trends and routes, opments in measures regulating the non-medical use of on the basis of seizures made in the subregions in which BOOKLET THE OF SCOPE cannabis in , and some jurisdictions in opiates are produced and along the routes to the main the United States of America. markets. The booklet concludes with a review of the supply of other opioids, in particular the trafficking trends and routes for and both at the global level and in the subregions most affected.

CANNABIS IS MORE POTENT BUT FEWER YOUNG PEOPLE SEE IT AS HARMFUL

PERCEPTION AMONG ADOLESCENTS CANNABIS HERB POTENCY

X INCREASE

∆-THC ∆-THC

   

9

  

  

  

  

        United States Europe United States

CANNABIS 3

GLOBAL SEIZURES GLOBAL NUMBER OF USERS  +%  Change from resin previous year -% herb CANNABIS | Cannabis supply CANNABIS |

, , tons tons cannabis herb cannabis resin  million

Outdoor cultivation of cannabis continues Cannabis supply to be more widespread than indoor cultiva- tion, but the increase in indoor cultivation is and production larger affects all regions Available data suggest that outdoor cannabis cultiva- Unlike other -based drugs, for which cultivation and tion continues to be more widespread at the global level production are concentrated in only a few countries, can- than indoor cannabis cultivation, a situation that did not nabis is produced in almost all countries worldwide. In change between the periods 2010–2014 and 2015–2019. the period 2010–2019, the cultivation of cannabis plant Overall, 89 countries reported outdoor cannabis cultiva- was reported to UNODC either through direct indicators tion and/or activities linked to outdoor (such as the cultivation or eradication of cannabis cannabis cultivation (such as eradication, seizures of can- and the dismantlement of cannabis-producing sites) or nabis plants and seizures of cannabis-producing sites) in indirect indicators (such as the of cannabis plants the period 2010–2019, while 65 countries reported data and the origin of cannabis seizures as reported by other in relation to indoor cultivation. Some countries reported Member States) by 151 countries, covering 97 per cent of both indoor and outdoor cannabis cultivation. the global population. Whereas outdoor cannabis production is found around Qualitative information on trends reported by Member the globe, most reported indoor cultivation of cannabis States suggests that there was an expansion in global can- continues to be concentrated in countries of Europe and nabis cultivation over the period 2010–2017, followed by North America (most notably the United States, followed a decline in 2018 and then a moderate increase in 2019. by Canada) and, to a lesser extent, in countries of Central 11 Source countries for cannabis

As most countries do not have systems in place to > Africa systematically monitor the area under cannabis cul- , Egypt, , , Eswatini and tivation, estimating the global area under cannabis Ghana cultivation is challenging. On the one hand, some countries report the total area under cannabis cul- > Europe tivation, but such estimates have severe limitations; Western and Central Europe: the , on the other hand, existing indicators on seizures and , eradication are widely available. Any indicator as it Czechia and relates to a single country is insufficient to provide South-Eastern Europe: Albania, and insight into the extent of cannabis cultivation and pro- Eastern Europe: the Russian Federation and Ukraine duction, but when the indicators for various countries are analysed together, they can point to those coun- > Asia tries where the most significant cannabis cultivation Near and Middle East/South-West Asia: a is likely to exist. Analysis of the various indicators , and WORLD DRUG REPORT 2021 REPORT DRUG WORLD over the period 2010–2019 suggests that the following : Kyrgyzstan and Kazakhstan countries are likely to have a significant area under cannabis cultivation in comparison with other coun- Transcaucasia: Azerbaijan and Armenia tries in the same region or subregion (given in order : and of importance, for each subregion): South-East Asia: the , the Lao People’s Democratic Republic, and > Americas > Oceania North America: , the United States of and America and Canada a Data for a number of direct indicators (e.g., “area under cannabis South America: Paraguay, Brazil and cultivation”) and for indirect indicators (e.g., “hectares of canna- bis eradicated”, “number of cannabis plants eradicated”, “number of cannabis sites eradicated”, “number of cannabis plants seized”, Central America: Guatemala, Costa Rica and “origin of cannabis seized” and “seizures of cannabis herb Honduras and resin”) are available and have been combined to identify those countries likely to have a significant area under cannabis Caribbean: Jamaica and Trinidad and Tobago cultivation.

and South America (including Chile, Colombia, increase in indoor cannabis cultivation was larger than the and Uruguay). Beyond those regions, indoor cannabis increase in outdoor cultivation. In that period, 49 coun- cultivation is found in Oceania (Australia and New Zea- tries (43 per cent of the countries that reported trends in land) as well as in a number of countries and territories in indoor cultivation) reported an increase in indoor cultiva- Asia, including in the Near and Middle East/South-West tion, while 23 countries (20 per cent) reported a decrease, Asia (Iran (Islamic Republic of), Israel and the State of resulting in overall “net growth” of 23 per cent among Palestine), in East and South-East Asia (, including all countries that reported indoor cannabis cultivation , China, Japan and Mongolia), in Central Asia trends. That is more than three times the corresponding (Kyrgyzstan and Uzbekistan) and Transcaucasia (Armenia “net growth” in the proportion of countries that reported and ). To date, no indoor cannabis cultivation has outdoor cannabis cultivation trends (7 per cent). Most of been reported to UNODC by countries in Africa. the increases in indoor cannabis cultivation were reported by countries in Europe and, to a lesser extent, by coun- Qualitative information on trends reported by Member tries in the Americas. 12 States also suggests that over the period 2012–2019, the Fig. 1 Qualitative information on trends in cannabis cultivation as Fig. 3 Reported trends in outdoor and indoor reported by national experts, 2010–2019 cannabis cultivation, 2012–2019 3 180 40 160 1 0 30 140 23 2 0 1 = :

x 120 20 e d I n 100 10 7

80 0 Proportioncountries of (percentage)

2 0 1 2 0 1 2 0 1 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 Increase Stable Decline "Net growth" Number of countries reporting "large increase" Outdoor Indoor

Number of countries reporting "some increase" Cannabis supply CANNABIS | Number of countries reporting "stable" Source: UNODC, responses to the annual report questionnaire. Number of countries reporting "some decrease" Note: The figure is based on qualitative information on trends in indoor and Number of countries reporting "large decrease" outdoor cannabis cultivation reported by Member States. “Net growth” is defined Cultivation trends index here as the number of countries reporting increases minus the number of countries reporting decreases in cannabis cultivation over the period 2012–2019, presented as a proportion of the total number of countries providing trends on outdoor cannabis Source: UNODC, responses to the annual report questionnaire. cultivation and on indoor cannabis cultivation, respectively. Note: The cultivation trends index is based on qualitative information on trends in cannabis cultivation reported by Member States. Calculations are based on the reports of 112 countries – on average, 34 countries per year over the period 2010–2019. The trend line is calculated on the basis of the number of countries reporting increases minus the number of countries reporting decreases (2 points for “large Fig. 4 Global number of cannabis herb and resin increase”, 1 point for “some increase”, 0 points for “stable”, -1 point for “some decrease”, -2 points for “large decrease”). seizure cases, 1998–2019

1,500,000 250 Fig. 2 Number of countries reporting indoor cannabis cultivation and their share among all countries with cannabis cultiva- 1,200,000 200 tion, 2010–2014 and 2015–2019 60 60% 6060%60 900,000 60% 60% 150

50 48% 5050%50 48% Number 600,000 50% 100 40 4040%40 40% 300,000 50 1998=100 Index: 30 3030%30 30%

Number 53 Number 53 45 45 0 0 20 2020%20 20%

10 10%10 1998 2001 2004 2007 2010 2013 10% 2016 2019

10 Proportion (percentage) Proportion (percentage) Number of seizure cases 0 00%0 Index of number of 0%seizure cases 2010–2014 2015–2019 2010–2014 2015–2019 Number of countries reporting indoor cannabis cultivationNumber of countries reporting indoor cannabis cultivation Source: UNODC calculations based on responses to the annual report Indoor as a proportion of all countries reporting cannabis cultivationIndoor as a proportionquestionnnaire. of all countries reporting cannabis cultivation

Source: UNODC, responses to the annual report questionnaire. Note: The number of seizure cases is based on cannabis herb and resin seizure cases reported by an average of 75 countries per year over the period 1998–2019 (57 Note: Figures are based on estimates reported by countries of the area under cannabis cultivation and/or countries in 2019). The index is a chained index of the number of cannabis herb and area of cannabis eradicated and/or number of cannabis plants eradicated and/or number of cannabis resin seizure cases reported by countries in at least two subsequent years; it is based sites eradicated and/or area available for cannabis cultivation after eradication. on the reporting of an average of 61 countries per year (52 countries in 2018–2019). 13 Fig. 5 Global cannabis seizures: quantities and seizure cases, 1998–2019

9,000 1,350,000 8,000 1,200,000 7,000 1,050,000 6,000 900,000 5,000 750,000 4,000 600,000 3,000 450,000 Quantities seized (tons) 2,000 300,000 cases seizure of Number 1,000 150,000 0 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Estimated additional quantities of cannabis herb and resin seized by non-reporting countries in 2019 WORLD DRUG REPORT 2021 REPORT DRUG WORLD Quantities of cannabis herb seized (as reported) Quantities of cannabis resin seized (as reported) Estimated additional quantities of cannabis herb and resin seized by non-reporting countries, excluding North America, in 2019 Quantities of cannabis herb and resin seized, excluding North America (as reported) Seizure cases of cannabis herb and resin (as reported) Estimated global cannabis seizure cases in 2019 (including estimated additional seizure cases)

Source: UNODC, responses to the annual report questionnaire. Note: A total of 121 countries reported seizure cases of cannabis herb or resin in the period 2009–2019, with an average of 62 countries per year (57 in 2019). This compares with a total of 166 countries reporting quantities of cannabis herb or resin seized in the period 2009–2019, with an average of 127 countries per year (120 in 2019). The estimates for 2019 are based on the assumption that the quantities of cannabis (herb and resin) seized and the number of cannabis (herb and resin) seizure cases remained unchanged in non-reporting countries in 2019 as compared with the previous year.

Quantities of cannabis seized continue decline in the Americas over the period 2009–2019 (and to decline, although probably not due to more than 40 per cent since 2015). The global quanti- reduced supply ties of cannabis (herb and resin) seized, excluding those reported in North America, were 44 per cent larger in The reported numbers of seizures of cannabis (herb and 2019 than in 2009. resin) showed an upward trend over the first decade of the new millenium, albeit with annual fluctuations, fol- In contrast to the decline in the quantities of cannabis lowed in recent years by a more stable trend. By contrast, (herb and resin) seized, qualitative information on trends the quantities of cannabis (herb and resin) seized at the reported by Member States (38 countries on average per global level, fell by 8 per cent in 2019 to 5,174 tons, the year) suggests an upward trend in cannabis trafficking fifth consecutive yearly decline. The quantities seized over the past decade, most notably after 2015, and the declined in all regions except Africa, and in all subre- upward trend continued in 2019. This discrepancy could gions except West and Central Africa, North Africa, the be the result of the set of countries reporting seizures Caribbean, Central America and Eastern Europe; however, being to some degree different from the set of countries some of this decline may have been partially due to the reporting trends by means of qualitative information. It non-reporting of some countries in 2019. may also be an indication that the overall decline in the quantities of cannabis seized may be a result of the inter- The overall decrease in the quantities of cannabis (herb diction of cannabis possibly becoming less of a priority 14 and resin) seized in the last decade reflects a 56 per cent for law enforcement agencies in a number of jurisdictions Fig. 6 Quantities of cannabis herb seized and Fig. 7 Quantities of cannabis herb seized, by country, 2019 reported trends in cannabis herb trafficking, 3 2009–2019 500 8,000 180 400 160 6,000 140 300

120 Tons 4,000 200 100 100 2,000 80

Quantities seized (tons) 60 0 0 40 India Trafficking trends index: 100 trends index: Trafficking 2010 = Spain Brazil Egypt Other Ghana Turkey Nigeria Mexico Pakistan 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Morocco Bahamas Paraguay Colombia Argentina CANNABIS | Cannabis supply CANNABIS | Africa Sudan (2018) United States Oceania Asia Americas Asia Africa Europe Various regions Europe South and Central America and Caribbean Source: UNODC, responses to the annual report questionnaire. North America Note: No seizure data provided for 2019 by Sudan; data refer to 2018. Trafficking trends index

Source: UNODC, responses to the annual report questionnaire. Americas (60 per cent of the global total), with South Note: The trafficking trends index is based on qualitative information on trends in America accounting for 34 per cent of the global total cannabis herb trafficking reported by Member States. The trend line is calculated on and North America for 17 per cent. In previous years, the the basis of the number of countries reporting increases minus the number of countries reporting decreases (2 points for “large increase”, 1 point for “some largest proportion of cannabis herb seized was reported increase”, 0 points for “stable”, -1 point for “some decrease”, -2 points for “large by countries in North America, which accounted for an decrease”). average of 50 per cent of the global total in the period 2008–2018. The next largest proportions of global quan- tities seized in 2019 were those of Africa (21 per cent) and in the Americas because of the and Asia (13 per cent), followed by Europe (6 per cent). legalization of cannabis for non-medical use in these jurisdictions,1 rather than an indication of a decline in The total quantity of cannabis herb seized worldwide in the supply of cannabis at the global level. 2019 was 40 per cent less than in 2009. That decline was mainly driven by the decreases in the reported seizure Decline in quantities of cannabis herb seized quantities in North America (decrease of 86 per cent), as in North America may be partly linked to there were marked declines reported by the United States the legalization of some cannabis markets in (decrease of 82 per cent), Mexico (decrease of 90 per that subregion cent) and Canada (decrease of 91 per cent). As mentioned above, the decline in reported quantities seized most The total global quantity of cannabis herb seized in 2019 likely reflects the changing legal framework concerning declined by 12 per cent compared with the previous cannabis, as Canada legalized cannabis for non-medical year, to 3,779 tons, the lowest figure since 1998. purposes in 2018 and some jurisdictions in the United The largest proportion of that amount was seized in the States have done so since 2014.2

1 United States Government Accountability Office, “State legalization: DOJ should document its approach to monitoring the effects of legalization”, Report to Congressional Requesters, GAO-16-1 2 See the below chapter of the present booklet, “Developments in (December 2015). measures regulating the non-medical use of cannabis”. 15 Most cannabis herb continues to be seized Origin, departure and transit of in the Americas cannabis herb, 2015–2019 Despite the marked declines, the country that reported seizing the largest quantities of cannabis herb in 2019 The countries that were most frequently mentioned was the United States, followed by Paraguay, a major in the annual report questionnaire as the main supplier of the markets in Brazil and other countries in countries of origin, departure and transit for can- the region,3 and Colombia. Of the 10 countries worldwide nabis herb in the period 2015–2019 were as follows reporting the seizure of the largest quantities of canna- (given in order of importance, for each subregion): bis herb, 7 were located in the Americas. The countries reporting the seizure of the largest quantities of canna- > Americas bis herb in 2019 in regions other than the Americas were North America: United States, Mexico and India, Nigeria and Morocco. Canada When considering a larger timespan, the period 2009– South America: Colombia and Paraguay 2019, the countries seizing the largest total amounts of Central America: Guatemala and Honduras cannabis herb worldwide were, in order of the amounts seized, the United States, Mexico, Paraguay, Colombia, Caribbean: Jamaica

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Nigeria, Morocco, Brazil, India and Egypt. > Africa Trafficking in cannabis herb continues to West and Central Africa: Ghana and Nigeria be mostly intraregional Southern Africa: Mozambique, South Africa, Most trafficking in cannabis herb continues to be intra- and Eswatini regional. In Africa, the Americas and Europe, countries East Africa: United Republic of , report that seized cannabis herb primarily comes from Uganda and Kenya or is destined for countries of the same region. By con- North Africa: Morocco trast, the most frequently mentioned countries of origin, departure and transit for cannabis herb seized in Oceania > Europe in the period 2015–2019 were countries in other regions Western and Central Europe: the Netherlands, (primarily the United States, followed by the Netherlands Spain and Albania and Canada). Similarly, in Asia, two countries from North America (Canada and the United States) were among South-Eastern Europe: Albania and Serbia the six most frequently mentioned countries of origin, Eastern Europe: the Russian Federation, Ukraine departure and transit of cannabis herb; those two coun- and Kazakhstan tries were mostly mentioned by countries or territories in East and South-East Asia, most notably by Hong Kong, > Asia China, followed by the Republic of Korea, Japan, China, South-East Asia: , Malaysia and Malaysia and Indonesia, as well as by Kuwait in the Near Thailand and Middle East. South Asia: India, Bangladesh and Nepal Reported increase in cannabis resin Near and Middle East/South-West Asia: trafficking Afghanistan and Lebanon Central Asia and Transcaucasia: Kyrgyzstan and In contrast to the decrease in the quantity of cannabis Kazakhstan herb seized, the global quantity of cannabis resin seized has shown a long-term upward trend, and qualitative information from Member States points to an increase in cannabis resin trafficking, especially since 2015.

16 3 UNODC, responses to the annual report questionnaire. Fig. 8 Quantities of cannabis resin seized and reported trends in cannabis trafficking, 1980–2019 3 Western and Central Europe 1,500 150 Eastern and South-Eastern Europe North Africa Near and Middle East/South-West Asia Other 1,000 100 Trafficking trends index

500 50 Quantities seized (tons)

0 0 100 trends index: Trafficking 2010 = 1980 1985 1990 1995 2000 2005 2010 2015 2020

Source: UNODC, responses to the annual report questionnaire. CANNABIS | Cannabis supply CANNABIS | Note: The trafficking trends index is based on qualitative information on trends in cannabis resin trafficking reported by Member States. The trend line is calculated on the basis of the number of countries reporting increases minus the number of countries reporting decreases (2 points for “large increase”, 1 point for “some increase”, 0 points for stable, -1 point for “some decrease”, -2 points for “large decrease”).

Trafficking in cannabis resin continues to Fig. 9 Quantities of cannabis resin seized in coun- be more geographically concentrated than tries reporting the largest total seizures, 2019 trafficking in cannabis herb 350 More than a third of the global quantity of cannabis resin 300 seized was intercepted in Western and Central Europe 250 (34 per cent) in 2019, followed by the Near and Middle 200

East/South-West Asia (33 per cent) and North Africa (30 Tons 150 per cent). These subregions accounted for close to 97 100 per cent of all cannabis resin seized worldwide in 2019. The largest quantities of cannabis resin were seized by 50 Spain, followed by Morocco, Afghanistan, Pakistan and 0 the Islamic Republic of Iran. Italy Spain Egypt Other France Turkey Algeria Pakistan Cannabis resin trafficked worldwide origi- Morocco Afghanistan nates mainly in Morocco and Afghanistan Morocco, which accounted for more than a fifth of all

mentions of the main “country of origin” in responses Iran Republic of Islamic Europe to the annual report questionnaire worldwide in the North Africa period 2015–2019, continues to be the most frequently Near and Middle East/South-West Asia mentioned source country of cannabis resin intercepted Various regions/subregions worldwide. Authorities reported some 21,000 ha under cannabis cultivation in 2019 (mostly grown in the Rif Source: UNODC, responses to the annual report questionnaire. area), down from 25,000 ha in 2018.4

4 Response submitted by Morocco to the annual report questionnaire for 2019. 17 On the basis of global patterns of seizures and reports Fig. 10 Main countries of origin of cannabis resin, as reported by by Member States, it appears that Moroccan cannabis Member States, 2015–2019 resin mainly supplies other markets in North Africa and Western and Central Europe. Some of it is also trafficked Morocco Afghanistan to Eastern Europe and South-Eastern Europe. Most of the Pakistan Moroccan cannabis resin destined for countries in Europe Lebanon is shipped to Spain and then on to France, the Netherlands Islamic Republic of Iran and other countries in the region. For years, including over Albania the period 2015–2019, Spain has been identified by other Kyrgyzstan European countries as the principal country of departure Spain and transit of cannabis resin, followed by the Netherlands Netherlands and France. Nepal India Afghanistan appears to be the second most important Other countries of Central Asia source country of cannabis resin worldwide, accounting for 18 per cent of all mentions of the main “country of 0 10 20 30 40 50 60 70 origin” in responses to the annual report questionnaire Number of times mentioned as country in the period 2015–2019. The two other most frequently of origin by reporting countries

WORLD DRUG REPORT 2021 REPORT DRUG WORLD mentioned countries of origin of cannabis resin seized were Pakistan and Lebanon. Those three countries have Source: UNODC, responses to the annual report questionnaire. been reported as source or transit countries of canna- Note: Figures are based on data from 71 countries providing such information to UNODC in the period bis resin intercepted in other countries in the Near and 2015–2019. The category of “Other countries in Central Asia” refers mainly to Kazakhstan and . Not all countries identified as "countries of origin” by other countries have been necessarily source Middle East/South-West Asia, most notably countries countries of cannabis resin; some of these countries may have been significant transit countries from of the Arabian peninsula. Cannabis resin originating in where the cannabis resin departed. Not all countries identified “as countries of origin” by other countries have been necessarily source countries of cannabis resin; some of these countries may have been Afghanistan has also been identified by countries in Cen- significant transit countries from where the cannabis resin departed. tral Asia, Eastern Europe and, to a lesser extent, Western and Central Europe. The Islamic Republic of Iran reported that the cannabis resin seized on its territory in the period 2015–2019 origi- nated mainly in Afghanistan and was trafficked either via Pakistan or directly from Afghanistan. In 2018, roughly 65 per cent of the cannabis resin seized in the Islamic Republic of Iran was destined for countries of the Arabian peninsula, 15 per cent for the Caucasus and 20 per cent for domestic consumption; in 2019, however, most cannabis resin seized in the Islamic Republic of Iran was destined for the country’s domestic market, the Caucasus coun- tries, Turkey and, to a lesser extent, the European Union. Cannabis resin seized in the Near and Middle East in the period 2015–2019 was reported to have originated mainly in Lebanon, as reported by Israel, Jordan, Lebanon, Oman, the State of Palestine and the Syrian Arab Republic. Some of the cannabis resin seized in Lebanon was also destined for markets outside the subregion, most notably Italy and, to a lesser extent, Brazil in 2018; also, most of the cannabis resin seized in in the period 2015–2019, including some 60 per cent of all cannabis resin seized in 2019, which was mostly destined for the local market 18 in Cyprus, originated in Lebanon. CANNABIS 3

Notwithstanding the ongoing debate as to whether the cannabis comprises one or more , the Cannabis use cannabis plant is currently considered to be monospe- cific ( L.) by the scientific community.5, 6 Global prevalence of cannabis use has There are two of the plant (sativa and indica) increased modestly while the number of and four varieties. To date, 120 phytocannabinoids have cannabis users continues to rise been recorded for Cannabis sativa, the main species of the cannabis plant.7 The main intoxicating or psychoac- Cannabis continues to be the most widely used drug tive constituent is Δ9-THC, while CBD is the principal worldwide. UNODC estimates that almost 4 per cent , for which there is no substantive evidence (range: 2.8–5.1 per cent) of the global population aged Cannabis use CANNABIS | that it is likely to cause THC-like psychoactive effects.8, 9, 10 15–64 years used cannabis at least once in 2019, the equivalent of some 200 million people (range: 141 mil- Produced in almost every country, cannabis herb con- lion–256 million). sists of the dried and crumbled and flowering tops of the cannabis plant, which are generally smoked. The overall number of people who used cannabis in the By contrast, cannabis resin, which is the concentrated past year is estimated to have increased by nearly 18 per of cannabis and plant, is produced mainly cent over the past 10 years (2010–2019), reflecting in part in a few countries in North Africa, the Middle East and an increase in the global population of 10 per cent over South-West Asia. is a cannabis product that can the same period. Since 2010, the past-year prevalence be extracted from any part of the plant. An increasing of other extract-based cannabis products is also Fig. 11 Trends in the global number of people who used, including edibles, vapes and dabs. use cannabis and reported trends in cannabis use, 2010–2019 In the past two decades, there have been rapid advances in cannabis plant cultivation techniques, in particular in 250 250 Europe and North America, which are mainly focused on 150 achieving a high Δ9-THC content. 200 50 In addition to the major transformation of cannabis culti- 150 vation in recent years, the cannabis market has diversified 100 -50 to the extent that it now comprises a broad range of prod- ucts with varying means of , potency and effects. 50 -150 Number of users (millions)

0 -250 100 index: 2010 = Use trends 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Cannabis users Cannabis use trends index 5 WHO Expert Committee on Drug Dependence, Critical Review: Cannabis Plant and Cannabis Resin (Geneva, 2018), sect. 1. Source: UNODC, responses to the annual report questionnaire. 6 The letter “L” denotes , who, in 1753, gave the botanical name to the plant. Notes: Estimated number of people aged 15–64 who used cannabis in the past year. 7 WHO, Critical Review: Cannabis Plant and Cannabis Resin. The cannabis use trends index is based on qualitative information on trends in 8 Ibid. cannabis use reported by Member States (on average, 67 countries per year over the period 2010–2019). The trend line is calculated on the basis of the number of 9 WHO Expert Committee on Drug Dependence, “Critical review countries reporting increases minus the number of countries reporting decreases (2 report: Cannabidiol (CBD)” (Geneva, 2018). points for “large increase”, 1 point for “some increase”, 0 points for “stable”, -1 point 10 WHO, Critical Review: Cannabis Plant and Cannabis Resin. for “some decrease”, -2 points for “large decrease”). 19 of cannabis use has thus increased by nearly 5 per cent. Fig. 12 Cannabis use among students aged 15–17, This increase in the number of people who use cannabis North Africa and the prevalence of cannabis use should be interpreted 6 with caution, however, because of the wide margins of error with respect to the estimates. Notwithstanding 5 these limitations, qualitative information on trends in 4 cannabis use, as reported by an average of 67 Member States per year, confirm the increase in cannabis use over 3 the period 2010–2019. 2 Cannabis use in Africa and Asia

Prevalence (percentage) Prevalence 1 In Africa, the annual prevalence of cannabis use in 2019 0 is estimated at 6.4 per cent of the population aged 15–64 Algeria Egypt Morocco Tunisia (range 3.8–8.8 per cent), corresponding to 47 million (2016) (2016) (2017) (2016) past-year users (range 28 million–64 million). Within the region, the subregion constituted by West and Central Lifetime use Past-year use Past-month use Africa has the highest prevalence of use, at 9.4 per cent, WORLD DRUG REPORT 2021 REPORT DRUG WORLD or an estimated 27 million past-year users, largely reflect- Sources: UNODC, responses to the annual report questionnaire; and reports of the Mediterranean School Survey Project on and Other ing past-year use of , where people Drugs for Algeria (2016), Egypt (2016), Morocco (2017) and Tunisia who use cannabis were estimated to comprise 10.8 per (2016). cent of the population, or 10.6 million people in 2018.11 Recent estimates of cannabis use are not available ranged between 5 per cent in Morocco (2017) and 2.5 per for any other country in the region. cent in Tunisia (2016) and Egypt (2016).14, 15

People in treatment for cannabis use disorders are com- The estimated annual prevalence of cannabis use in Asia monly reported in Africa, where half of those in drug is much lower than in other regions, at 2 per cent, but treatment in 2019 were reported as being treated for owing to the size of the population, nearly one third (61.5 cannabis use. On the basis of drug treatment data from million) of the estimated global number of cannabis users West Africa covering the period 2014–2017, the majority reside in the region. In India, in 2018, more than 3 per of people (73 per cent) who were treated for drug use dis- cent of the population aged 18 and older, and less than 1 orders in the subregion were treated for cannabis as the per cent of adolescents (aged 10–17) – nearly 31 million primary drug, which corresponds to a rate of almost 2 per people in total – had used a cannabis product in the past 100,000 adult population being treated for cannabis use year.16 In Thailand, an estimated 1.3 per cent of the adult disorders in each reporting year.12 Similarly, among people population were past-year cannabis users in 2019; in Indo- in South Africa who attended specialist drug treatment nesia, the figure was 1.4 per cent.17, 18 Although up-to-date services in 2019, cannabis was reported as the primary surveys among the general population have not yet been or secondary drug for the majority of people who were conducted in the region, surveys of young people were treated for drug use disorders, in particular among those conducted in both Afghanistan and Kazakhstan in 2018. aged 20 or less.13 Among students aged 15–17 in countries In Afghanistan, 5.5 per cent (range 4.5–6.7 per cent) of in North Africa, the past-year prevalence of cannabis use students aged 13–18 had used cannabis in the past year.

11 UNODC and Nigeria, Drug Use in Nigeria 2018 (Vienna, 2019). 14 UNODC, responses submitted by Algeria, Egypt, Morocco and Tunisia to the annual report questionnaires. 12 UNODC and ECOWAS, West African Epidemiology Network on Drug Use (WENDU) Report: Statistics and Trends on Illicit Drug Use and 15 Mediterranean School Survey Project on Alcohol and Other Drugs Supply 2014–2017 (2019). surveys (MEDSPAD) for the period 2016–2017 for the same countries. 13 Siphokazi Dada and others, “Monitoring and other drug 16 Atul Ambekar and others, Magnitude of Substance Use in India abuse treatment admission in South Africa: July-December 2019, (New Delhi, Ministry of Social Justice and Empowerment, 2019). phase 47”, South African Community Epidemiology Network on Drug 17 Thailand, Office of the Narcotics Control Board and Administra- Use (SACENDU) updates (Cape Town, South Africa, Alcohol, Tobacco tive Committee for Academic Network, “National and other Drug Research Unit, South African Coun- survey on substance use in Thailand, 2019” (2019). 20 cil, 2020). 18 UNODC, responses to annual reports questionnaire. Among young people out of school, mainly in Kabul, 7.3 Fig. 13 Trends in cannabis use among the adult per cent (range 5.5–9.0 per cent) reported past-year use population, selected countries with recent 3 of cannabis,19 whereas in Kazakhstan, between 1.2 and data, South America 2.3 per cent of students aged 13–18 reported past-year 16 use of cannabis.20 14 In the absence of survey data, the cannabis use percep- 12 tion index indicates that cannabis use increased in Africa 10 and Asia over the period 2010–2019. More recently, an 8 increase in cannabis use was reported, as based on expert perceptions, by more than half of the countries in Africa 6 and Asia that submitted responses to the annual report 4 questionnaire in 2018 and 2019. 2

Annual Annual prevalence (percentage) 0 Cannabis use in Central and South America 2008 2011 2017 2007 2013 2014 2018 2008 2010 2012 2014 2016 2018 2003 2008 2013 2019

and the Caribbean Cannabis use CANNABIS | The past-year prevalence of cannabis use in the Carib- Argentina bean, Central America and South America is lower than Bolivia (Plurinational State of) the global average, at 3.4 per cent, 3.1 per cent and 3.5 per Chile Colombia cent, respectively, of the adult population, correspond- ing to over 12 million people who used cannabis in the Source: UNODC, responses to the annual report questionnaire, multiple past year in those subregions. Among the four countries years.

Fig. 14 Cannabis use among students aged 14–17 in the Caribbean, 2016 30

25

20

15

Percentage 10

5

0 Male students Female students Male students Female students Past-year prevalence Past-month prevalence Antigua and Barbuda The Bahamas Barbados Belize Dominica Guyana Haiti Jamaica Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Trinidad and Tobago

Source: Organization of American States, Inter-American Drug Abuse Control Commission, A Report on Students’ Drug Use in 13 Caribbean Countries (OEA/Ser.L/XIV.6.46).

19 UNODC and Afghanistan, “Youth study on substance use and , 2018” (forthcoming). 20 UNODC and Kazakhstan, Scientific and Practical Centre of , “Youth survey on drug use and health in Kazakhstan, 2018” (forthcoming). 21 in South America with data for multiple years, cannabis Fig. 15 Trends in cannabis use among the population use in Argentina and Chile nearly doubled from 2008 aged 18 and older, United States, 2010–2019 to 2017/18, while the trend in cannabis use remained 200 generally stable in Bolivia (Plurinational State of) and Colombia. In Central America, recent information on 175 the extent of drug use among secondary school students showed that the past-year prevalence of cannabis use in 150 Costa Rica was 5.1 per cent (2018) and in El Salvador was 6.6 per cent (2018). 125

Cannabis use in the past year among the adult popula- 100 = Index: 2010 100 tion in Caribbean countries is estimated at 3.4 per cent in 2019, whereas a survey among students aged 14–17 in 75 13 Caribbean countries in 2016 showed that the average past-year prevalence of cannabis use was 17.5 per cent 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 among boys and 10.3 per cent among girls. The average Lifetime use past-month prevalence among boys (11.6 per cent) in the Past-year use 13 countries surveyed was nearly double that of girls.21 Past-month use

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Daily or near-daily use

Cannabis use is still on the increase Source: United States, Substance Abuse and Mental Health Services in North America Administration, Results from the 2019 National Survey on Drug Use and Health: Detailed Tables (Rockville, Maryland, 2020). Past-year cannabis use in the Americas increased from an estimated 6.6 per cent (40 million past-year users) in 2010 to 8.8 per cent of the adult population (59 million twofold over the period 2010–2019. Prior to that, between past-years users) in 2019. Within the Americas, cannabis 2002 and 2009, the prevalence of cannabis use in the use is much higher in North America (14.5 per cent, or past month had increased by 10 per cent among the adult 47 million users) than in other subregions. population. In 2019, over 29 million people aged 18 and older were estimated to be past-month users of cannabis, Cannabis use continues to increase of whom 45 per cent, or 13.8 million people, were daily in the United States or near-daily23 users of cannabis.24 Change in the cannabis market in the United States In 2018 and 2019, in the United States, past-month can- in the past decade has resulted in a larger number of nabis use among people aged 18 and older was higher users of the drug and, more dramatically, in a higher fre- among men than among women, and more so among quency of and in larger quantities people who were socially disadvantaged (e.g., without 22 of cannabis being consumed. While the past-year and completed college education, unemployed).25 past-month prevalence of cannabis use among the adult population (aged 18 and older) in the United States have Compared with cannabis use among the adult population increased by 60 per cent and 75 per cent, respectively, in the United States, the levels of past-year and past- the prevalence of daily or near-daily use increased almost month use of cannabis among high-school students have remained stable over the past 10 years (2011–2020); in 21 Organization of American States, Inter-American Drug Abuse Control Commission, A Report on Students’ Drug Use in 13 Caribbean Countries: Antigua and Barbuda, The Bahamas, Barbados, Belize, Dominica, Gre- 23 Daily or near-daily use is defined as use of a substance for 20 days or nada, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St. Lucia, St. Vincent more in the past month. and the Grenadines, Trinidad and Tobago (OEA/Ser.L/XIV.6.46) (2016). 24 United States, Substance Abuse and Mental Health Services Admin- 22 See, for instance, Miles K. Light and others, “Market size and demand istration, Key Substance Use and Mental Health Indicators in the United for marijuana in ” (Colorado, United States, Colorado States: Results from the 2019 National Survey on Drug Use and Health, Department of Revenue, 2016), which argues that the amount of HHS Publication, No. SMA 18-5068, NSDUH Series H-53 (Rockville, cannabis used per day is strongly correlated with the number of days Maryland, Center for Behavioral Health Statistics and Quality, 2020). of use per month, and that 80 per cent of the cannabis consumed in 25 Based on data from United States, Substance Abuse and Mental Colorado was consumed by daily users, who comprised 20 per cent of Health Services Administration, Results from the 2019 National Survey 22 the past-year cannabis users in Colorado. on Drug Use and Health: Detailed Tables (Rockville, Maryland, 2020). Fig. 16 Recent cannabis use, by sociodemographic Fig. 17 Trends in cannabis use among high-school profile of users, United States, 2018–2019 students (combined 8th, 10th and 12th 3 grades), United States, 2011–2020 22 20 115 18 16 110 14 105 12 10 100 8 95 6 4 90 2 Index: 100 = 100 = Index: 2011 85 0 80 Men

Other 75 Past-month prevalence (percentage) Women Full-time Part-time 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Unemployed Some college CANNABIS | Cannabis use CANNABIS |

College graduate College Annual prevalence Past-month prevalence High school graduate Less than high school Daily or near-daily use Gender Education Employment 2018 2019 Source: United States, National Institute on Drug Abuse, Monitoring the Future, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students” (December 2020). Source: United States, Substance Abuse and Mental Health Services Administration, Results from the 2019 National Survey on Drug Use and Health: Detailed Tables (Rockville, Maryland, 2020). However, the trends in cannabis use among high-school students are in stark contrast to the decline in tobacco 2020, 14.6 per cent of high-school students reported and alcohol use, the two most commonly used substances past-month use of cannabis.26 However, there has been by adolescents. The past-month prevalence of tobacco a significant increase in daily or near-daily use of canna- use among high-school students declined from nearly bis in the past two years (2019 and 2020). In 2020, the 12 per cent in 2011 to 5 per cent in 2020, while the past- daily or near-daily use of cannabis was estimated at 4.1 month prevalence of alcohol use declined from 26 per per cent among high-school students compared with cent to 21 per cent over the same period.29 nearly 1 per cent in 1991. The increase in daily or near- daily use of cannabis is more significant among 8th and Cannabis use in Canada also continues to increase 10th grade students, and in 2020 was at its highest level 27 In North America, comparatively high levels of cannabis among all high-school students since 1991. Cannabis use use have also been reported in Canada. In 2020, more among adolescents is found to be related to impaired than a quarter of people aged 16 and older reported – showing lagged effects on inhibitory control non-medical use of cannabis in the past year.30, 31 Past-year (e.g., self-control) and working memory, and concurrent effects on delayed memory and perceptual reason- development”, American Journal of , vol. 176, No. 2 (February ing (ability to think and reason using pictures or visual 2019). information).28 29 United States, National Institute on Drug Abuse, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students”. 30 Since 2017, the Canadian Cannabis Survey has been implemented 26 United States, National Institute on Drug Abuse, Monitoring in the country with the aim of obtaining detailed information about the Future, “2020 data from in-school surveys of 8th-, 10th-, and cannabis users and behaviours relative to its use. Since cannabis 12th-grade students” (December 2020). users are oversampled in the cannabis survey, its results are not com- 27 Lloyd D. Johnston and others, “Monitoring the Future: National Survey parable with the general population surveys such as the Canadian Results on Drug Use, 1975–2020 – Overview, Key Findings on Adolescent Tobacco, Alcohol and Drugs Survey, the most recent of which was Drug Use (Ann Arbor, Michigan, University of Michigan, Institute for conducted in 2017. Social Research, 2021). 31 According to the most recent Canadian Tobacco, Alcohol and Drugs 28 Jean-Francois G. Morin and others, “A population-based analysis of Survey in 2017, for comparison, 15 per cent of aged 15 and the relationship between substance use and adolescent cognitive older (or 4.4 million) had used cannabis in the past 12 months (19 per 23 Fig. 18 Cannabis use, by sex and age group, Canada, past-year cannabis users reported eating or drinking can- 2018–2020 nabis products and 33 per cent reported vaping cannabis 60 products.34 2018 50 2019 2020 Cannabis use remains relatively stable in 40 Australia and New Zealand 30 The annual prevalence of cannabis use in Australia and New Zealand is estimated at 12.1 per cent of the adult 20 population. In both countries, past-year cannabis use 10 has remained stable over the past 10 years, with some increase in 2019.

Annual Annual prevalence (percentage) 0 Overall Men Women 16–19 20–24 25 and In Australia,35 the highest past-year prevalence of canna- older bis use was reported among young people aged 20–29, although over the period 2016–2019, past-year use of can- Source: , “Cannabis use for non-medical purposes among Canadians (Aged 16+)”, Data blog https://health-infobase.canada.ca/ nabis increased significantly among older people (aged cannabis/. 50 and older), essentially indicating an ageing cohort of

WORLD DRUG REPORT 2021 REPORT DRUG WORLD cannabis users in Australia. The older age group is also more likely to report regular cannabis use than other cannabis use was higher among men than among women age groups, with nearly half of past-year users aged 50 and higher among both sexes aged 20–24 than among and older using cannabis once a week or more. Past-year other age groups. Data suggest an increase since 2018 in past year use across both sexes, and among those aged 25 and older.32 Fig. 19 Trends in cannabis use among the adult popu- lation, Australia and New Zealand, 2007–2019 During the COVID-19 pandemic in 2020, more than half (56 per cent) of people who had used cannabis in the 16 past 12 months reported that they had used the same 14 amount of cannabis as they had prior to the pandemic, 12 while those reporting using less cannabis than prior to 10 the pandemic and those reporting using more cannabis 8 were less than a quarter each (22 per cent). Nearly one third (31 per cent) of cannabis users aged 24 and younger 6 reported using more cannabis, a higher proportion than 4 among those aged 25 and older (19 per cent).33 2 0 While cannabis users reported using more than one Annual prevalence (percentage)

method of cannabis consumption (non-medical use), 2007 2008 2010 2013 2016 2017 2018 2019 was the most common method (79 per cent) reported in Canada in 2020. However, that is a decrease Australia New Zealand from the 89 per cent of users who reported smoking can- Source: UNODC, responses to the annual report questionnaire, different nabis in 2018. Other common methods reported in 2020 years. included eating edible cannabis products in (53 per Note: The adult population in Australia is defined as those aged 14 and older, while cent) and vaping (31 per cent). In 2018, 43 per cent of in New Zealand it is those aged 15 and older.

cent among those aged 15–19; 33 per cent among those aged 20–24; 34 Health Canada, “Cannabis use for non-medical purposes among and 13 per cent among those aged 25 and older). Canadians (Aged 16+)”, Data blog https://health-infobase.canada.ca/ 32 Health Canada, “Cannabis use for non-medical purposes among cannabis/. Canadians (Aged 16+)”, Data blog https://health-infobase.canada.ca/ 35 Australian Institute of Health and Welfare, National Drug Strategy cannabis/. Household Survey 2019, Drug Statistics Series, No. 32 (Canberra, 24 33 Health Canada, “Canadian cannabis survey 2020: summary”. 2020). cannabis use also increased significantly over the period Cannabis use is increasing among the 2016–2019 among those who had completed 12 years or adult population but remains stable among 3 less of education and those who were living in the most secondary school students in Western and disadvantaged socioeconomic areas. Central Europe The past-year prevalence of cannabis use in Western Fig. 20 Trend in cannabis use among the population aged 50 and older, by age group, Australia, and Central Europe has fluctuated between 6 per cent 2001–2019 and nearly 8 per cent over the past decade (2010–2019). In 2019, 7.8 per cent of the population aged 15–64 (25 10 million people) had used cannabis in the past year. Can- nabis use in the past year among young people aged 8 15–34 is particularly high, at an estimated 15 per cent (18 million people). Past-month use of cannabis in 2019 6 was estimated at about 3.0 per cent of the adult popu- lation. Moreover, it is estimated that about 1 per cent of 4 in that subregion (mainly States members of the CANNABIS | Cannabis use CANNABIS | European Union) are daily or near-daily cannabis users. 2 That is, they have used the drug on 20 days or more in

Annual Annual prevalence (percentage) the past month. The majority of them (60 per cent) are 0 36 50–59 Ages 60 and over under 35, and around three quarters are male.

2001 2016 2019 According to the latest survey, in 2019, of secondary school students aged 15–16 in 34 countries in Europe, Source: Australian Institute of Health and Welfare, National Drug Strategy cannabis is the most widely used drug, with an average Household Survey 2019, Drug Statistics Series, No. 32 (Canberra, 2020). past-year prevalence of 13 per cent: 15 per cent among

Fig. 21 Trends in cannabis use, selected countries, Western and Central Europe 16 14 12 10 8 6 4 2

Annual Annual prevalence (percentage) 0 2008 2013 2018 2005 2014 2017 2006 2009 2015 2018 2008 2011 2014 2017 2009 2014 2015 2016 2017 2018 2009 2014 2016 2019 2009 2011 2013 2015 2017 2010 2012 2014 2015 2016 2018 2011/12 2014/15 2016/17 2018/19 England France Italy Netherlands Norway Spain Sweden and ,

Sources: UNODC, responses to the annual report questionnaire; and EMCDDA, “Statistical Bulletin 2020: prevalence and patterns of drug use in the general population”.

36 EMCDDA, European Drug Report 2020: Trends and Developments (Luxembourg, Publications Office of the European Union, 2020). 25 Fig. 22 Trends in cannabis use among secondary boys and 11 per cent among girls. There is great variation school students aged 15–16, Europe, in cannabis use among students from country to coun- 1995–2019 try, ranging from an annual prevalence of 4.8 per cent 25 in and 5.1 per cent in Iceland to 23 per cent in Czechia and Italy. Overall, cannabis use remained 20 quite stable among secondary school students in Europe aged 15–16 over the period 2007–2019, with an average 15 lifetime prevalence of about 16 per cent and past-month 37 10 prevalence of about 13 per cent. 5 Association between the decreasing trend Prevalence (percentage) Prevalence 0 in adolescents perceiving cannabis as harm- Lifetime use Past-year use Past-month use ful and increasing use of cannabis 1995 1999 2003 2007 2011 2015 2019 There has been considerable research into risk and pro- tective factors for substance use, especially in relation to Source: EMCDDA and European School Survey Project on Alcohol and cannabis, as it is the substance most commonly used by Other Drugs, ESPAD Report 2019: Results from the European School Survey adolescents. Among these factors, the perceived descrip-

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Project on Alcohol and Other Drugs, EMCDDA Publications Series (Luxembourg, Publications Office of the European Union, 2020). tive norms, that is, the use of drugs (both prevalence and

Fig. 23 Trends in cannabis use among secondary school students aged 15–16, selected countries with a high prevalence of use, Europe, 1999–2019 45 45 40 Czechia 40 Italy 35 35 30 30 25 25 20 20 15 15 10 10 5 5 Prevalence (percentage) Prevalence Prevalence (percentage) Prevalence 0 0 Lifetime use Past-year use Past-month use Lifetime use Past-year use Past-month use 45 45 45 1999 2003 2007 201140 2015 2019 1999 2003 France2007 2011 2015 2019 40 France 40 Spain 35 35 35 30 30 30 25 25 25 20 20 20 15 15 15 10 10 10 5 5 (percentage) Prevalence 5 Prevalence (percentage) Prevalence 0 (percentage) Prevalence 0 Lifetime use Past-year0 use Past-month use Lifetime use Past-year use Past-month use Lifetime use Past-year use Past-month use

1999 2003 2007 2011 2015 2019 1999 2003 2007 2011 2015 2019

Source: EMCDDA and European School Survey Project on Alcohol and 37 EMCDDA and European School Survey Project on Alcohol and Other Other Drugs, ESPAD Report 2019: Results from the European School Survey Drugs, ESPAD2003 Report 2019:2007 Results from2011 the European2015 School Survey2019 Project on Alcohol and Other Drugs, EMCDDA Joint Publications Series Project on Alcohol and Other Drugs, EMCDDA Joint Publications Series 26 (Luxembourg, Publications Office of the European Union, 2020). (Luxembourg, Publications Office of the European Union, 2020). Fig. 24 Trends in recent cannabis use, risk perception and perception of availability of cannabis among 10th grade students, United States, 1991–2020 3

90 25 80 70 20 60 15 50 40 10 30 (percentage) 20 5 Perceptions (percentage) Perceptions 10 month prevalence of cannabis use 0 0 - Past 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 CANNABIS | Cannabis use CANNABIS | Past-month prevalence of cannabis use Perceived ease of availability of cannabis Risk perception of harm from smoking cannabis occasionally Risk perception of harm from smoking cannnabis regularly

Source: United States, National Institute on Drug Abuse, Monitoring the Future, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students” (December 2020). frequency of use among friends), as well as injunctive explains the long-term increase in cannabis use among norms (how much others approve of use) and expec- adolescents is difficult to determine. It is clear, however, tancies (expected outcomes from use, including the that there is an association between a lower perception perception of risk of harm) have been strongly associ- of risk and higher use of cannabis, as observed in the ated with cannabis use by adolescents.38, 39, 40, 41 United States, Europe and America and the Carib- bean, although the strength of the association, at least In recent years, the debate about medical use of canna- in the case of United States, may no longer be as strong bis and measures allowing non-medical use of cannabis as it used to be. The strength of this association may vary in the United States and elsewhere have led adolescents but, in both the United States and Europe, it is character- to perceive cannabis as less harmful than they previously ized by a steady decline in the risk perception of cannabis 42 had. How much this reduced perception of harmfulness among adolescents and a long-term increase in regular cannabis use, with some irregular annual fluctuations. 38 Julia D. Buckner, “College cannabis use: the unique roles of social norms, motives, and expectancies”, Journal of Studies on Alcohol and Drugs, vol. 74, No. 5, pp. 720–726 (September 2013). Among 10th grade students in the United States, there is 39 Lyndon D. Johnston and others, Monitoring the Future National: Survey a clear association between the past-month prevalence Results on Drug Use, 1975–2015 – Overview, Key Findings on Adolescent of cannabis use and the perception of risk (from either Drug Use (Ann Arbor, Michigan, University of Michigan, Institute for Social Research, 2016). occasional or regular use of cannabis), but the strength 40 Dagmar Dzúrová, Jana Spilková and Martin Vraný, “Substance misuse of this association has weakened in the past 20 years. and its risk perception in European teenagers”, Children’s Geographies, In the period 1992–2000, the lower the perception of vol. 14, No. 2 (2016), pp. 203–216. 41 Daniela Piontek and others, “Individual and country-level effects of risk or harm arising from cannabis use was, the higher cannabis-related perceptions on cannabis use: a multilevel study the past-month cannabis use among students (Pearson among adolescents in 32 European countries”, Journal of Adolescent correlation coefficient of -0.98). Health, vol. 52, No. 4 (April 2013), pp. 473–479. 42 Aaron L. Sarvet and others, “Recent rapid decrease in adolescents’ perception that marijuana is harmful, but no concurrent increase in However, over the period 2001–2020, the inverse associa- use”, Drug and , vol. 186 (2018), pp. 68–74. tion between risk perception and current use of cannabis 27 was not as strong as in the previous decade – the Pearson Fig. 25 Trends in recent cannabis use and risk perceptions correlation coefficient43 was -29 for past-month cannabis concerning the use and availability of cannabis among use and perception of risk or harm from occasional can- secondary school students aged 15–16, Europe, 1995–2019 nabis use, and -16 between regular cannabis use and the 100 10 perception of harm from regular cannabis use. Between 1992 and 2000, past-month cannabis use more 80 8 than doubled at the same time as the perception of risk or harm from occasional cannabis use declined by one 60 6 third and perception of risk or harm from regular use declined by 20 per cent. From 2001 to 2020, past-month 40 4 cannabis use increased by 16 per cent as the perception (percentage) of risk or harm from occasional cannabis use declined 20 2

by 39 per cent and the perception of risk or harm from (percentage) Perceptions

regular cannabis use declined by 42 per cent. Similar find- month prevalence of cannabis use 0 0 - ings were reported in another study that looked at data 1995 1999 2003 2007 2011 2015 2019 for 12th grade students in a national school survey and Past for those in the corresponding age group in the national Past-month use of cannabis

WORLD DRUG REPORT 2021 REPORT DRUG WORLD survey among the general population.44 Perceived availability of cannabis Risk perception of harm from smoking cannabis once or twice Similarly, in Europe the perception of risk or harm from Risk perception of harm from smoking cannabis regularly trying cannabis once or twice among students aged 15–16 declined by nearly half, and the perception of risk or harm Source: EMCDDA and European School Survey Project on Alcohol and Other Drugs, ESPAD Report 2019: Results from the European School Survey Project on Alcohol and Other Drugs, from smoking cannabis regularly declined by a quarter EMCDDA Joint Publications Series (Luxembourg, Publications Office of the European Union, over the period 1995–2019, in parallel with an overall 2020). increase in past-month cannabis use. Also, a study among adolescents aged 15–17 in Latin such as perceived availability of cannabis, that is, how American and Caribbean countries in 2016 concluded easy it is to obtain cannabis. In the United States, the that there was a significant association between a low perceived availability has declined by 28 per cent over perception of harm, a strong perception of the benefits the past 20 years among 10th grade students. In other of using cannabis and the use of cannabis (odds ratio words, fewer adolescents think it is easier to obtain can- of 1.61 for lifetime use, 1.62 for past-year use and 1.66 nabis than in the past. for past-month use). However, there was a much stron- ger association between friends’ use of cannabis and In the United States, the decreasing perception of risk self-reported past-year or past-month use of the drug from occasional or regular use of cannabis is considered (odds ratio of 8.5 and 8.9, respectively). It was also noted to be a spillover effect as debates over measures allowing in this study that, despite favourable perceptions, the the medical and non-medical use of cannabis in the states majority of the respondents (55 per cent) nevertheless considering those measures extend to other states, and reported no intention of using cannabis even if it were the result of an increase in regular cannabis use, which legally available. 45 comes to be perceived as less risky among users, as well as media coverage of the medical use of various cannabis The different grades of association between risk per- products in many states containing claims of the medical ceptions and regular cannabis use could be explained benefits of cannabis products, including those of CBD.46, 47, by other factors that have determined the trends in use, 48 Nevertheless, further research is required to determine

43 The Pearson correlation coefficient is a measure of linear correlation between two sets of data. 46 UNODC, World Drug Report for the years 2016–2019. 44 Sarvet and others, “Recent rapid decrease in adolescents’ perception 47 Wayne Hall and Megan Weier, “Has marijuana legalization increased that marijuana is harmful, but no concurrent increase in use”. marijuana use among US youth?”, JAMA Paediatrics, vol. 171, No. 2 45 Maria Inês Gandolfo Conceição and others, “Perception of harm and (February 2017), pp. 116–118. benefits of cannabis use among adolescents from Latin America and 48 Sarvet and others, “Recent rapid decrease in adolescents’ perception 28 Caribe”, Texto and Contexto – Enfermagem, vol. 28 (2019). that marijuana is harmful, but no concurrent increase in use”. Fig. 26 Trends in smoking, cannabis use and risk perceptions related to smoking and the use of cannabis among adolescents in the United States (10th grade) and Europe (aged 15–16), 1995–2019 3 United States Europe 40 90 35 80 30 70 60 25 50 20 40 15 30 10 20

Prevalence (percentage) Prevalence 5 10 0 0

1995 1999 2003 2007 2011 2015 2019 1995 1999 2003 2007 2011 2015 2019 Perception of risk/harm (percentage) Cannabis use, past month , past month Cannabis use CANNABIS | Risk perception of harm from smoking cannnabis regularly Risk perception of harm from smoking one or more packs of cigarettes per day

Sources: United States, National Institute on Drug Abuse, Monitoring the Future, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students” (December 2020); and EMCDDA and European School Survey Project on Alcohol and Other Drugs, ESPAD Report 2019: Results from the European School Survey Project on Alcohol and Other Drugs, EMCDDA Joint Publications Series (Luxembourg, Publications Office of the European Union, 2020). Note: In order to show comparable trends, the data points for the United States Monitoring the Future survey that are presented are those that correspond to the years of the survey of the European School Survey Project on Alcohol and Other Drugs. whether the differences in a lower perception of risk or the past month, compared with nearly 20 per cent of harm from cannabis use and actual use of cannabis are adolescents in Europe. However, the decline in cigarette causally associated with policy frameworks or are simply smoking among adolescents in the United States is offset established secular trends in wider society.49 by the increase in vaping, which increased from a past- month prevalence of 14.2 per cent in 201550 to 23.5 per In both Europe and the United States, the association cent in 2020.51 By contrast, 14 per cent of students in between use and the perception of risk or harm is much Europe in 2019 reported using e-cigarettes in the past more linear in the case of the smoking of cigarettes than month.52 for cannabis use, as the past two decades or more show a sharp decrease in cigarette use, which was more pro- Cannabis has become more potent in the nounced among adolescents in the United States than in Europe, together with an increasing perception of risk United States and Europe, but adolescents or harm from regular cigarette smoking. The trends for perceive cannabis as less harmful than Europe and the United States are similar although the before levels of use are quite dissimilar: more adolescents use There is clear discordance between the risk of harm per- cannabis in the United States than in Europe (the past- ceived by adolescents in using cannabis and the potential month prevalence of cannabis use in 2019 was 18 per risk that cannabis products of increasingly greater cent among 10th grade students in the United States potency could pose to their health. The percentage of compared with 7 per cent among adolescents in Europe), but fewer adolescents use cigarettes in the United States than in Europe: nearly 4 per cent of 10th grade students 50 The collection of information on the use of vaping began in 2015. in the United States in 2019 had smoked cigarettes in 51 United States, National Institute on Drug Abuse, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students”. 52 EMCDDA and European School Survey Project on Alcohol and Other 49 Ibid. Drugs, ESPAD Report 2019. 29 Fig. 27 Potency of cannabis and perception of risk from cannabis use among adolescents, Europe and United States, 1995–2019 Perception among adolescents of risk/harm of smoking cannabis regularly Perception among adolescentsPerception of among80 adolescents ofCannabis potency (Δ9--THC content) risk/harm of smoking cannabisrisk/harm regularly of smoking cannabis regularly inin cannabiscannabis herbherb 70 16 80 80 60 14 70 70 50 12 60 60 40 10 50 10

50 Percentage 30 8 40 8

40 Percentage 20 Percentage Percentage Percentage 6 Percentage Percentage 30 30 6 10 4 20 20 4 0 10 10 2 0 0 1995 1997 01999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019

Europe1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2017 2019 WORLD DRUG REPORT 2021 REPORT DRUG WORLD United States Europe Europe Linear (Europe)trend (Europe) United States United statesStates Linear (UnitedTrend (United States) States) Linear (Europe) Europe Linear (Europe) United States Linear (United States) United States Sources: University of Mississippi,Linear (United National States) Center for Natural Products Research, Research InstituteLinear of Pharmaceutical (Europe) Sciences, Quarterly Report No. 140, Potency Monitoring Program (June 2019); EMCDDA, Statistical Bulletin 2000; UNODC, annualLinear report questionnaire;(Europe) EMCDDA and European School Survey Project on Alcohol and Other Drugs, ESPAD Report 2019: Results from the European School SurveyLinear Project (United on Alcohol States) and Other Drugs, EMCDDA Joint Publications Series (Luxembourg, Publications Office of the European Union, 2020); and United States, National Institute on Drug Abuse, Monitoring the Future, “2020 data from in-school surveys of 8th-, 10th-, and 12th-grade students” (December 2020). Note: For Europe, the Δ-9-THC potency is presented as an unweighted average of 26 European countries, including data from the countries of the European Union (excluding Denmark, Greece and Lithuania), as well as from Norway and the United Kingdom.

Δ9-THC in cannabis herb seized increased fourfold in As the scientific literature suggests, daily cannabis use the United States between 1995 and 2018 and almost has been associated with a greater likelihood of psychotic doubled in Europe between 2002 and 2018. Moreover, disorders among users than among people who have in some jurisdictions in Canada and the United States, never used cannabis, and the likelihood of such disor- other cannabis products, such as cannabis concentrates ders is nearly five times greater among those who, on and edibles, may have a potency of 70 per cent or more,53 a daily basis, use cannabis with a high Δ-9-THC content making the substance more potent and its users more (Δ-9-THC ≥ 10 per cent).54, 55 prone to health consequences. Despite that trend, over that same period of time, the percentage of adolescents who consider regular use of cannabis to be harmful has significantly declined.

54 Marta Di Forti and others, “The contribution of cannabis use to vari- ation in the incidence of psychotic disorder across Europe (EU-GEI): a multicentre case-control study”, The Lancet Psychiatry, vol. 6, No. 5 (May 2019). 55 Rebecca Keupper and others, “Continued cannabis use and risk of 53 See, for instance, UNODC, World Drug Report 2019, booklet 5, Canna- incidence and persistence of psychotic symptoms: 10 year follow-up 30 bis and (United Nations publication, 2019). cohort study”, BMJ, vol. 342 (2011). CANNABIS 3

Developments in measures regulating the non-medical use of cannabis Permitted quantities of cannabis products for personal possession in public in Canada As of April 2021, legal provisions allowing the non-med- ical use of cannabis have been approved in Canada and Adults are allowed to possess a maximum of 30 g of dried Uruguay, as well as in 20 jurisdictions (17 states, 2 terri- cannabis (or equivalent) in public at any time. tories and the District of Columbia) of the United States. 30 g of dried cannabis is deemed equivalent to: The common feature of the legislation in Canada and most jurisdictions in the United States is that it generally 150 g of fresh cannabis, or allows for the production and sale by for-profit industry 450 g of edible cannabis, or of cannabis products for non-medical use in the relevant 2,100 g of liquid product, or jurisdictions. There are differences in the level of reg- 7.5 g of concentrates (solid or liquid), or ulation and control between the non-medical and the 30 cannabis plant seeds, or medical use of cannabis,56 and the are being 4 cannabis plants that are not budding or flowering implemented in different local contexts and dynamics, which is likely to have a different impact on the devel- Source: Canada, Department of Justice, “Cannabis legalization and ”. opment of cannabis markets in each jurisdiction, on the Available at www.justice.gc.ca/eng/cj-jp/cannabis/). extent of non-medical use of cannabis and on other and safety and criminal justice outcomes.

Legalization of non-medical use of cannabis legislation permits adults (aged 18 and over) to legally in Canada access a range of cannabis products, including edibles, and topicals, which regulation came into force The use of cannabis for medical purposes has been a year after the Act, in October 2019. permitted in Canada since 1999 through exemptions granted by the Minister of Health for medical and sci- The establishes a cooperative framework entific purposes or in the public interest and according for regulating cannabis between the federal, provincial to its domestic law. In July 2018, the Canadian Parlia- and territorial governments. The federal government ment passed the Cannabis Act, which establishes a legal is responsible for regulating cannabis production and framework that provides regulated access for medical has implemented a series of measures to help ensure the non-medical usecannabis of regulating in measures Developments CANNABIS | and non-, setting out a series of con- that the risks and harms of cannabis are appropriately trols governing the production, distribution, sale and addressed, including licences, permits and authoriza- possession of cannabis. The objectives of the legisla- tions, security clearances, a cannabis tracking system, tion are, among others, “to protect public health and advertising and promotion rules, and packaging and label- public safety” and, in particular, to keep cannabis away ling requirements. The provinces and territories regulate from young people (minors under 18 years of age) and the distribution and sale of cannabis, subject to “to reduce illicit activities in relation to cannabis”.57 The minimum federal conditions. Provinces and territories also have the ability to establish stricter rules for public possession, personal cultivation of cannabis plants, and 56 For more information on cannabis regulations in each jurisdiction in Canada, the United States and Uruguay, see the summary table at the minimum age; they are responsible for establishing local end of the present chapter. rules related to where cannabis may be consumed. 57 Canada, Department of Justice, “Cannabis legalization and regula- tion”. Available at www.justice.gc.ca/eng/cj-jp/cannabis/. 31 Provinces and territories have each adopted a slightly TRENDS IN CANNABIS USE IN CANADA different approach to how they license and operate their distribution and retail systems, in recognition of the unique circumstances of each jurisdiction.58 In most provinces, the retail licensing regime is similar to that PAST YEAR which regulates the sale of alcohol, and cannabis is sold USE through licensed retailers (private sector), provincial retail stores (public sector) and online. Some provinces have established government-run at both    the distribution and retail level, others have adopted a model with a mix of private and public retailers … daily use in the past year: ...  ...  ...  and/or distributors, while others have both private dis- tributors and retailers.

PAST MONTH To monitor the outcome of the Cannabis Act and reg- USE ulations, the has invested in monitoring and surveillance activities; principal among    those is a cannabis survey that established a baseline in WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2017 and is repeated annually in order to provide objec- tive information on knowledge, attitudes and behaviours … “stoned” or “high” on a around cannabis, and the regular collection of data on typical use day for three the cannabis market. or four hours (among past-month users): ...  ...  Use of cannabis is on the increase in Canada ...  In 2020, 27 per cent of people (31 per cent of men and 23 per cent of women) aged 16 and older reported that  they had used cannabis in the past 12 months and 18 per  cent in the past month, showing increases since 2018.   Those reporting having used cannabis in the last 30 days did so on an average of 14.4 days. Also, 36 per cent of past-month users reported that they would be “stoned” PAST or “high” on a typical use day for three or four hours. THREE MONTH Smoking was the most common method of using can- USE nabis; dried cannabis flower and edible products, which have been allowed since 2019, were the main cannabis products used in the past 12 months.59

 .  An analysis of changes over time – before the Act was passed, just after it was passed and one year after it was … daily/near-daily use (among users passed – shows increases in recent and regular use of can- in the past three months): nabis. By the end of 2020, 7.9 per cent of people who had ... . used cannabis in the past three months reported daily or near-daily use of the drug; the prevalence was similar ... . Q  for men and women but was higher among adults under Q  ... . 45 than among older ones.60 Q   58 See https://www.canada.ca/en/health-canada/services/drugs-medi- cation/cannabis/-regulations/provinces-territories.html. Sources: Health Canada, “Canadian cannabis survey 2020: summary”, and previous 59 Health Canada, “Canadian cannabis survey 2020: summary”. years; Michelle Rotermann, “Looking back from 2020, how cannabis use and related 60 Michelle Rotermann, “Looking back from 2020, how cannabis use 32 behaviours changed in Canada”, Health Reports (Statistics Canada, Avril 2021). and related behaviours changed in Canada”, Health Reports (Statistics Fig. 28 Cannabis products used by people who reported use in the Fig. 29 Frequency of obtaining cannabis from an illegal/ past 12 months, Canada, 2019 and 2020 unlicensed or legal/licensed source among people who 3 used cannabis in the past 12 months, Canada, 2020

Dried flower/ Never Edible products Rarely Cannabis concentrates/ extracts Sometimes Cannabis vape pens/ cartridges Mostly Cannabis oil for oral use 2020 Always 2019 0 10 20 30 40 50 60 0 10 20 30 40 50 60 70 80 Proportion of people who used cannabis in the past year Proportion among people who used cannabis (percentage) in the past year (percentage) Legal/licensed source Illegal/unlicensed source

Source: Health Canada, “Canadian cannabis survey 2020: summary”. Source: Health Canada, “Canadian cannabis survey 2020: summary”. Note: Respondents to the survey could choose multiple responses. Therefore, the total of percentages for all categories is more than 100 per cent. Note: Respondents to the survey could choose multiple responses.

Users of are increasingly preferred source.61 It would seem that the cannabis purchasing their product from the legal market products in the legal market captured the share of the In 2020, more than half of the people in Canada who used cannabis market in the first year after legalization to the cannabis in the past 12 months reported that they had extent that those products were available, accessible and 62 never obtained or purchased cannabis from an illegal or low-priced for the consumers. unlicensed source. Moreover, 41 per cent reported a legal In 2020, those who reported cannabis use in the past 12 storefront as their usual source of purchasing cannabis, months also indicated that they typically spent close to a significantly higher proportion than in 2019 when just 67 Canadian dollars on cannabis products each month. under a quarter of past-year cannabis users reported legal On average, women reported spending less on cannabis storefronts as their usual source for obtaining cannabis. than men. Cannabis users who reported cannabis use in Developments in measures regulating the non-medical usecannabis of regulating in measures Developments CANNABIS | Among the 45 per cent of people who had used cannabis the past 30 days spent more, approximately 49 Canadian in the past 12 months and had obtained it from illegal dollars in the past 30 days, to obtain cannabis from legal or unlicensed sources, most had bought the drug from sources in addition to a similar amount spent to obtain 63 someone they knew (58 per cent). Past-year cannabis cannabis from illegal sources. users also reported obtaining cannabis from an unreg- ulated or unauthorized online retailer (22 per cent), a dealer (20 per cent) or an unregulated or unauthorized storefront (19 per cent). Prices, safe supply and qual- ity of cannabis products were the three main reasons mentioned for obtaining cannabis from the respondents’ 61 Health Canada, “Canadian cannabis survey 2020: summary”. 62 Michael J. Armstrong, “Legal cannabis market shares during Canada’s first year of recreational legalisation”, International Journal of , vol. 88 (2021). Canada, April 2021). 63 Health Canada, “Canadian cannabis survey 2020: summary”. 33 Fig. 30 Household expenditure on cannabis products Fig. 31 Monthly cannabis retail sale, Canada, for non-medical use, Canada, 2014–2020 October 2018–December 2020 1,800 300 1,600 1,400 250 1,200 200 1,000 800 150 600 400 100 200

Million Canadian dollars 50 0 0 Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar May 2014 Q1 2014 Q3 2015 Q1 2015 Q3 2016 Q1 2016 Q3 2017 Q1 2017 Q3 2018 Q1 2018 Q3 2019 Q1 2019 Q3 2020 Q1 2020 Q3 Retail sales (millions of Canadian dollars) Licensed Unlicensed 2018 2019 2020

Source: Statistics Canada, Table 36-10-0124-01. Detailed household final Source: Statistics Canada: table 20-10-0008-01. Retail trade sales by consumption expenditure, Canada, quarterly. province and territory. WORLD DRUG REPORT 2021 REPORT DRUG WORLD

Cannabis retail is increasing in Canada, with large Fig. 32 Monthly cannabis retail sale, by province, corporations investing in the cannabis market Canada, January–December 2020 By the end of 2020, there were 1,369 cannabis retail 100 stores in Canada, double the number of stores in exis- tence nationally at the end of 2019.64 By December 80 2020, the 12-month retail sale of cannabis stood at 2.6 billion Canadian dollars, more than double the previous 60 12-month retail sale period (1.2 billion Canadian dollars). 40 The criteria for obtaining a retail licence differs by 20 jurisdiction. For example, , the most populous province in Canada, with a population of 14.7 million, 0 began using a retail system in which licences were issued Jul Jan Jun Oct Apr Feb Sep Dec Aug Nov Mar to operators by means of a lottery, but the province has May

since abandoned that approach and removed the cap on Retail sales (millions of Canadian dollars) Ontario retail licences in favour of an open market for private can- nabis retail in 2020. Another example is Alberta, which, Rest of Canada by the end of 2020, accounted for 40 per cent of all retail Source: Statistics Canada: table 20-10-0008-01. Retail trade sales by outlets in Canada, and where, in September 2020, the province and territory. provincial government amended the Gaming, Liquor and Cannabis Regulation65 to remove a restriction that had in the province.66 By the end of 2020, there were 2 stores previously prevented any one person or group from con- per roughly 100,000 population in Ontario, while there trolling more than 15 per cent of cannabis licences issued were nearly 13 stores per 100,000 population in Alberta.67 In the past couple of years, major multinational alcohol and tobacco companies have invested in the acquisition 64 Business of Cannabis, “A look at cannabis store counts by province”, of a large number of shares in major cannabis production 11 January 2021. 65 Province of Alberta, Gaming, Liquor and Cannabis Act, Alberta Regulation 143/1996 with amendments up to and including Alberta 66 CBC News, “Alberta lifts cap on percentage of cannabis market Regulation 176/202, Current as of November 1, 2020, Office retailers can own”, 13 October 2020. 34 Consolidation. 67 Contribution from Canada. companies in Canada.68, 69, 70, 71 As market analysts have commercial determinants of health83 have been recog- stated, one aim of this investment is for alcohol and nized in the scientific literature in cases where corporate 3 tobacco companies to capitalize on the developing can- interests secure a favourable policy environment or nabis market in order to diversify and, according to media prevent public policies that could affect the sale of com- reports, expand their product range, for example, through modities or products, and the profit thereby generated, the production of cannabis-infused beverages or the use that collectively impact the health of the population.84, 85 of vaping technology from the for use The Cannabis Act has a number of important regulatory with cannabis extracts.72, 73, 74, 75 Some have raised concerns controls, including controls to prevent corporate control that the largest cannabis production companies would or takeover, plain packaging restrictions and advertising also be owned or partly owned by alcohol and tobacco restrictions. companies and that the development of cannabis markets could be dictated more by commercial considerations The retail cannabis market in Canada is likely to con- than by public health and safety concerns.76, 77, 78, 79, 80 tinue to evolve as jurisdictions adapt their regulatory approaches, as supply chains develop and as cannabis Lessons learned from the tobacco, alcohol and ultra-pro- product offerings are diversified. Overall, the implemen- cessed food industries, as well as the pharmaceutical tation of laws permitting the non-medical use of (as in the opioid crisis), have illustrated, in the in Canada is still in its nascent stages, and it may take context of non-communicable , how corpo- several years of monitoring to clarify how the cannabis rate activities and domination of the market can be a market has evolved and to identify its dynamics and the determinant of poor health of the population.81, 82 Such impact of legalization on public health and safety, among other outcome measures. Differences in the implementa- 68 Nathan Reiff, “10 biggest Canadian marijuana companies”, tion of the legislation in the provinces and territories may Investopedia, 5 April 2021. also vary in impact and thus require contextual analysis 69 Constellation Brands, “Constellation Brands’ $5 billion CAD ($4 billion USD) investment in closes following share- at the provincial and territorial levels. holder and Canadian Government approval”, 1 November 2018. 70 Sean Williams, “Cronos Group’s $1.8 billion investment from Altria has closed. Now what?”, The Motley Fool, 17 March 2019. Developments in cannabis regulation in 71 , “Management’s discussion and analysis report (Q1 Uruguay 2019 MD and A)” (2019). (2019). 72 Jennifer Maloney and David George-Cosh, “Big brewer makes a play In 2013, the Government of Uruguay approved legislation for marijuana beverages”, , 29 October 2017. (Law No. 19.172) regulating the cultivation, production, 73 Diane Caruana, “Imperial brands to invest £75 million in Canadian cannabis brand”, Vaping Post, 9 August 2019. dispensing and use of cannabis for non-medical pur- 74 David George-Cosh, “Canopy Growth beverage head to depart amid poses. In accordance with the legislation, cannabis can be sluggish sales”, BNN Bloomberg, 9 December 2020. obtained by individuals aged 18 and older for non-medical 75 Shariq Khan, “Canada dry? Cannabis-infused fizzle due to production, distribution challenges”, , 29 October 2020. purposes through registration with the national Insti- 76 Craig Giammona, “The next big thing is ”, Bloomberg tute for the Regulation and Control of Cannabis and by Businessweek, 10 October 2018. choosing one of three options: (a) purchase in authorized 77 Sean Williams, “Altria grossly overpaid for its equity stake in pot ; (b) membership of a club; or (c) domestic stock Cronos Group”, The Motley Fool, 11 December 2018. 86 the non-medical usecannabis of regulating in measures Developments CANNABIS | 78 Wayne Hall and others, “Public health implications of legalising the cultivation. production and sale of cannabis for medicinal and recreational use”, The Lancet, vol. 394, No. 10208 (October 2019). The total quantity of cannabis permitted per person, as 79 Beau Kilmer, “How will cannabis legalization affect health, safety, obtained through any of the three mechanisms, cannot and social equity outcomes? It largely depends on the 14 Ps”, American Journal of Drug and , vol. 45, No. 6 (July 2019), pp. 664–672. 80 Rosalie Liccardo Pacula and others, “Developing public health reg- 83 Robert West and Theresa Marteau, “Commentary on Casswell (2013): ulations for marijuana: lessons from alcohol and tobacco”, American the commercial determinants of health”, Addiction, vol. 108, No. 4 Journal of Public Health, vol. 104, No. 6 (June 2014), pp. 1021–1028. (April 2013), pp 686–7. 81 Nicholas Freudenberg, “The manufacture of lifestyle: the role of cor- 84 Illona Kickbusch, Luke Allen and Christian Franz, “The commercial porations in unhealthy living”, Journal of Public , vol. 33, determinants of health”, The Lancet, vol. 4, No. 12 (December 2016). No. 2 (May 2012), pp. 244–256. 85 Melissa Mialon, “An overview of the commercial determinants of 82 Robin Ireland and others, “Commercial determinants of health: health”, Global Health, vol. 16, No. 74 (2020). advertising of alcohol and unhealthy during sporting events”, 86 See also World Drug Report 2018, booklet 3, Analysis of Drug Markets: Bulletin of the World Health Organization, vol. 97, No. 4 (April 2019), Opiates, Cocaine, Cannabis, Synthetic Drugs (United Nations publica- pp. 290–295. tion, 2018). 35 exceed 480 g per year. Initially, the Government of Uru- In 2019, the Government of Uruguay also established the guay set a limit of Δ-9-THC content at 2 per cent and National Fund for Research on Cannabis, which is aimed CBD content at 6–7 per cent. In 2017, the Government at financing scientific research on cannabis use in the introduced two varieties, with a Δ-9-THC content of 9 country. In addition, in 2019, the Senate passed a law to per cent or less and CBD content of almost 3 per cent.87 promote and allow access to cannabis for medical pur- Overall, the implementation of the regulations has been poses. As a result, the National Programme for Access to slow and gradual; as at January 2021, five companies had Medicinal and Therapeutic Cannabis was created within been granted licences to cultivate, produce and distribute the Ministry of Public Health.93 Finally, on 1 February cannabis products for non-medical use. However, those 2021, the price of a 5-g package of dried cannabis flower products include only dried cannabis flower because dispensed by participating pharmacies was set at 350 psychoactive edibles and extracts are not allowed in Uruguayan pesos (approximately $8.20).94 Uruguay.88 In the 2018 survey on drug use in Uruguay, it was esti- By April 2021, 16 pharmacies had been licensed to dis- mated that about 12 per cent of men and 5.8 per cent pense cannabis for non-medical use, and 45,129 people of women had used cannabis in the past month, with a had registered in order to acquire cannabis from those total past-month prevalence of 8.9 per cent among the pharmacies.89 Over the period July 2017–May 2020, over population aged 15–65, or about 158,000 users.95 This 833,000 cannabis transactions (packages of 5 g each) reflects an increase in past-month use of more than one WORLD DRUG REPORT 2021 REPORT DRUG WORLD took place in pharmacies, totalling 4,166 kg of cannabis third since 2014 (when measures allowing non-medical products sold. Of those sales, 59 per cent were made use of cannabis were introduced in Uruguay), while past- in the capital city. It is estimated that out of the total year cannabis use increased by more than 50 per cent number of cannabis users registered with pharmacies, 4 over the same period. out of 10 people bought between 5 and 15 g of cannabis products, averaging at 16.6 g of monthly cannabis pur- Fig. 33 Non-medical use of cannabis, Uruguay, chases in May 2020.90 However, the supply of cannabis 2001–2018 products to pharmacies is still limited, with the result that pharmacies currently do not cover the demand of regis- 40 tered users, especially in parts of the country where there is a greater concentration of registered cannabis users.91 30

By April 2021, an additional 12,386 people had registered 20 for domestic cultivation of cannabis and 171 cannabis clubs, with a total membership of 5,152 people, had been Percentage 10 registered. Thus, more than 62,000 people in total – more than one third of the estimated number of past-month 0 cannabis users in 2018 – had access to the regulated can- 2001 2006 2011 2014 2018 nabis market in Uruguay at that time,92 which is still a relatively small share of the overall population of can- Lifetime prevalence nabis users in the country. Past-year prevalence Past-month prevalence

Source: Uruguay, VII Encuesta Nacional Sobre Consumo de Drogas en 87 John Hudak, Geoff Ramsey and John Walsh, “Uruguay’s cannabis law: Población General: Informe de Investigación (, Junta Nacional de pioneering a new paradigm” ( D.C., Centre for Effective Drogas, Observatorio Uruguayo de Drogas, 2019). Public Management, Brookings Institution, 2018). 88 Uruguay, Institute for the Regulation and Control of Cannabis website (www.ircca.gub.uy/). 93 Uruguay, Institute for the Regulation and Control of Cannabis, 89 Ibid. “Memoria Institucional 2019”, approved by the Institute Board of 90 Uruguay, Institute for the Regulation and Control of Cannabis, Directors on 27 February 2020. “Mercado regulado del cannabis: informe X”, 31 May 2020. 94 Uruguay, Institute for the Regulation and Control of Cannabis 91 Uruguay, Institute for the Regulation and Control of Cannabis, “Mer- (www.ircca.gub.uy/). cado regulado del cannabis: informe VIII”, 31 October 2019. 95 Uruguay, VII Encuesta Nacional Sobre Consumo de Drogas en Población 92 Uruguay, Institute for the Regulation and Control of Cannabis web- General: Informe de Investigación (Montevideo, Junta Nacional de 36 site (www.ircca.gub.uy/). Drogas, Observatorio Uruguayo de Drogas, 2019). Fig. 34 Trend in cannabis use among second- 13 per cent of students who used cannabis in the past ary school students aged 13–17, Uruguay, year were considered high-risk or problematic users of 3 2003–2018 cannabis.98 While the level of cannabis use has remained 25 stable among adolescents over the past two years, past- ) e

g year cannabis use among adolescents increased by one a t

n 20 third over the decade 2007–2018. Over the years, there e c

r has also been a narrowing of the gap in the past-year e p ( 15 use of boys and girls. e c n e

l The impact of the provisions regulating the non-medical a 10 v

e use of will only become evident in r p

l the coming years, once more information on the outcome

a 5 u measures related to public health and public safety is n n

A made available. 0 2003 2005 2007 2009 2011 2016 2018 2014 Cannabis regulations and their Overall Boys Girls implementation in the United States In the United States, a total of 47 states had allowed the Source: Uruguay, VIII Encuesta Nacional sobre Consumo de Drogas en Estudiantes de Enseñanza Media: Informe de Investigación (Montevideo, medical use of cannabis by the end of 2020, 36 states, as Junta Nacional de Drogas, Observatorio Uruguayo de Drogas, 2020). well as the District of Columbia, Guam, Puerto Rico and the United States Virgin Islands, had approved or had in place a comprehensive programme for the broad medical In 2018, the highest past-month prevalence of cannabis use of cannabis, and 11 states had allowed a more limited use was reported among young people aged 19–25 (20.8 medical use of cannabis purely for specific disorders and per cent), followed by those aged 26–35 (16.4 per cent). only of specific, low Δ-9-THC potency products.99 According to the survey, about 25,500 people were esti- mated to be daily or near-daily users of cannabis, or 9.9 A medical cannabis programme is considered by the per cent of those who reported cannabis use in the past National Conference of State Legislatures to be com- year (13.1 per cent of males and 5.2 per cent of females). prehensive if the programme: (a) provides for protection Around 16 per cent of those who reported cannabis use from criminal penalties for using cannabis for a medi- in the past year and more than one third of regular can- cal purpose; (b) provides for access to cannabis through nabis users (those who consumed cannabis products daily cultivation, or some other system that or weekly) were considered to have a harmful pattern of is likely to be implemented; (c) allows a variety of strains cannabis use.96, 97 or products, including those with more than a “low Δ-9- THC” content; (d) allows either smoking or vaporization Another survey on drug use among secondary school of some cannabis products, plant material or extract; students aged 13–17 in Uruguay revealed that, in 2018, and (e) is not a limited trial programme, that is, allowed the non-medical usecannabis of regulating in measures Developments CANNABIS | 19.7 per cent of adolescents had used cannabis in the past as a trial for a limited period and not open to the public. year, while 11.1 per cent had used it in the past month. The highest prevalence of past-year cannabis use in that The 11 states that have limited measures on the medical overall age group was among 17-year-olds (34.1 per cent) use of cannabis may allow the use of cannabis products followed by those aged 15–16 (20.9 per cent). Moreover, with low Δ-9-THC and high CBD content for a set of defined medical conditions (although in limited situa- tions and for varying medical conditions) or as a legal 96 The International Statistical Classification of Diseases and Related Health Problems (eleventh revision) defines harmful (patterns of) use of substances as a pattern of substance use that has caused damage to a person’s physical or mental health or has resulted in behaviour 98 Uruguay, VIII Encuesta Nacional sobre Consumo de Drogas en Estudi- leading to harm to the health of others. antes de Enseñanza Media: Informe de Investigación (Montevideo, Junta 97 Uruguay, VII Encuesta Nacional Sobre Consumo de Drogas en Población Nacional de Drogas, Observatorio Uruguayo de Drogas, 2020). General: Informe de Investigación (Montevideo, Junta Nacional de 99 United States, National Conference of State Legislatures, “State Drogas, Observatorio Uruguayo de Drogas, 2019). Medical Marijuana Laws”, April 2021. 37 Map 1 Jurisdictions in the United States that allow non-medical use of cannabis or medical use of cannabis and those that do not allow access to cannabis, April 2021

WA VT ME AK MT ND MN NH OR ID WI NY MA SD* MI RI WY CT IA PA NJ NE OH IL IN DE NV UT WV MD CO VA DC CA KS MO KY NC TN HI OK SC AZ NM AR MS* AL GA

Adult and medical use regulated programme TX LA Adult use only, no medical regulated programme FL Comprehensive medical cannabis programme CBD/Low-THC programme No public cannabis programme AS GU MP VI PR WORLD DRUG REPORT 2021 REPORT DRUG WORLD Source: National Conference of State Legislatures, April 2021. * Limited adult possession and growing allowed. No regulated production or sale: DC. The boundaries and names shown and the designations used on this map do not imply official endorsement or acceptance by the United Nations.

defence as protection from criminal penalties for using their states. Moreover, by April 2021 the state legisla- cannabis for a medical purpose. For example, Alabama tures in New Mexico, New York and had also allows the use of cannabis products for “debilitating passed legislation allowing non-medical use of canna- epileptic conditions, life-threatening seizures, wasting bis by the adult population in those states. As a result, syndrome, , etc., and any other severe con- by April 2021, 17 state-level jurisdictions in the United dition resistant to conventional ”. In its similar States,102 plus the District of Columbia, Guam and the programme, by comparison, the State of Georgia allows Northern Mariana Islands, had allowed the non-medical the use of cannabis products with low Δ-9-THC content use of cannabis, and most had also allowed commercial and high CBD content for medical conditions such as production by for-profit industry.103, 104 It is worth noting end-stage , sclerosis (amyotrophic lateral scle- that all the states that have legalized the non-medical use rosis and multiple sclerosis), seizure disorders, Crohn’s of cannabis previously had measures in place permitting disease, mitochondrial diseases, Parkinson’s disease and the medical use of cannabis. sickle cell disease.100 Among the states that have approved measures that Other states, for example, South Dakota (prior to legal- allow the non-medical use of cannabis, in Virginia, while izing non-medical use of cannabis) and Nebraska, have the bill for legalizing the non-medical use of cannabis limited trial programmes on medical use of cannabis that will be effective as of July 2021, the actual provisions of are not open to the public. the bill are subject to re-enactment by the 2022 session of the state General Assembly. In Montana, the applica- In the 2020 presidential elections, voters in four tion for issuing licensing for commercial production of states, Arizona, Montana, New Jersey and South Dako- cannabis products will begin in January 2022. ta,101 approved or voted for measures that allowed the non-medical use of cannabis by the adult population in

102 In the United States, cannabis is federally prohibited as a substance 100 Ibid. listed in schedule I of the Controlled Substances Act. 101 On February 8, 2021, a circuit judge in South Dakota ruled that the 103 Home cultivation is not allowed in the State of Washington. The measure was unconstitutional, finding that it violated the state’s sin- number of plants allowed in each State varies. gle-subject rule and that it constituted a revision of the constitution 104 United States, National Conference of State Legislatures, “Cannabis 38 rather than an amendment. overview”, 8 April 2021. Cannabis regulations allowing the non-medical use to sell cannabis for non-medical use.106, 107 In Michigan, of cannabis are not implemented uniformly in each municipalities can place greater restrictions on cannabis 3 state where cannabis has been legalized businesses than the state legislation. Such restrictions The level of implementation of the legislation permit- may include capping the number of licences or banning ting the non-medical use of cannabis varies across state the commercial production and sale of cannabis for jurisdictions and may even include different approaches non-medical use altogether. Residents can also petition within the same jurisdiction. For example, some states their town for such ordinances. that have legalized the non-medical use of cannabis allow city administrations to formulate their own cannabis reg- Cannabis market is regulated similarly to the ulations and give options within those cities to not permit alcohol market and is overseen by a variety of the sale of cannabis. In Colorado, 67 per cent of the state regulatory bodies jurisdictions (216 jurisdictions) do not allow medical and In the United States, cannabis remains a controlled sub- non-medical retail of cannabis products, while only 25 stance at the federal level. As with other subject matters, per cent of jurisdictions (81) allow both medical and retail such as regulating the production or sale of alcohol or licences for the non-medical use of cannabis. gun control, each state has its own measures and control mechanisms that differ considerably across the country. For instance, while the federal Government regulates the Fig. 35 Share of county jurisdictions in Colorado, United States, according to licensing status production of alcoholic beverages, taxes alcohol sales for the medical and non-medical use of and requires a health warning by the Surgeon General on cannabis, January 2019 alcoholic products, alcohol sales are regulated primarily by state and local governments. Notwithstanding the Both medical and retail different context and ethos, states that have measures (non-medical) cannabis allowing the non-medical use of cannabis regulate the licences are allowed cannabis market in a manner similar to that of the alcohol 25% market, for example, by prohibiting the sale of cannabis to people under 21 years of age, as in the case of alcohol, for which the in all states is 21 years, or Only retail (non- Both medical and retail by licensing commercial enterprises to produce, market medical) cannabis (non-medical) sale of and sell for profit a wide range of cannabis products. licences are allowed cannabis is banned 4% 67% In states such as California, Colorado and , Only medical cannabis specialized cannabis regulatory bodies have been estab- licences are allowed lished, whereas in and Michigan, the cannabis 4% market is regulated by the departments of revenue or of taxation. Some states, such as Alaska, and Washington, have tasked the existing alcohol or liquor

boards with cannabis market regulation. In Washington the non-medical usecannabis of regulating in measures Developments CANNABIS | Source: Marijuana Enforcement Division of Colorado. and Oregon, the legalization were written to mirror state alcohol control laws, designating state liquor In Oregon, of the state’s 36 counties and 241 cities, 17 control boards as the lead regulatory agency. In Colorado, counties and 81 cities have prohibited either the estab- the Task Force on the Implementation of Amendment 64, lishment of licensed producers, processors, wholesalers which was charged with developing recommendations to and/or retailers of cannabis products for non-medical the state legislature for the state’s cannabis regulatory use.105 In California, the largest state to legalize the framework, included members from the cannabis and non-medical use of cannabis, only about 20 per cent alcohol industries. In general, the role of health agencies of cities, that is, 89 out of 481 cities, allow retail shops 106 Patrick McGreevy, “Court dismisses cities’ lawsuit challenging canna- bis deliveries in California”, Times, 18 November 2020. 105 Oregon Liquor Control Commission, Record of Cities/Counties 107 Patrick McGreevy, “Legal pot sales fall short of expectations in Prohibiting Licensed Recreational Marijuana Facilities, February 2021. California” Los Angeles Times, 3 January 2019. 39 Fig. 36 Number of cities in California, United States, that allow a different level of business operations for the medical and non-medical cannabis 350 Storefront 300 Delivery 250 Any form of retail Cultivation 200 Manufacturing Number 150

100

50

0 Business for medical Business for medical Business for medical Both businesses for and non-medical use of use allowed, for non- use banned, non- medical and non- cannabis allowed medical use banned medical use allowed medical use banned

Source: Lynn D. , Amanda Z. Naprawa and Alisa A. Padon, “Assessment of incorporation of lessons from in city and county laws WORLD DRUG REPORT 2021 REPORT DRUG WORLD regulating legal marijuana in California”, Journal of American Medical Association (JAMA) Network Open, vol. 3, No. 6 (June 2020). Note: Data included in the was for 58 counties and 476 cities in California; the authors could not find cannabis-related regulatory data for 5 of California’s 481 cities.

to include public health best practices, as in the case taxes must be low enough to compete with the illegal of tobacco control framework, in regulatory debates or cannabis market but not so low as to encourage frequent frameworks for non-medical use of cannabis in those use, whereas public health-oriented price strategies states has remained limited, if any.108 recommend keeping prices high enough to discourage consumption and cover the external costs of commer- Different limits for possession and home cultivation cial sector activity. In many states, rather than public of cannabis health-oriented strategies, tax rates have been set to With the exception of the District of Columbia (56 g compete with the illicit market and to generate reve- or less) and Maine (71 g or less), which permit the pos- nue.109 However, part of the revenue from taxing cannabis session of larger quantities, most states allow for the is utilized for implementing the regulatory framework possession of up to 28.5 g of cannabis. In addition, all and investing, among other things, in the state educa- states permit the home cultivation of around six plants, tion system and public health initiatives for preventing with a varying number of plants that can be flowering; the harm caused by the non-medical use of cannabis.110 Michigan and Colorado (as of 2018), which allow for the In Colorado, for example, the first $40 million of home cultivation of up to 12 plants, are exceptions. The tax revenue raised from wholesale cannabis products is conditions allowing home cultivation of cannabis vary transferred to the Public School Capital Construction but may include measures such as plants having to be Assistance Fund for public school construction projects, grown out of public view or cultivation being subject to and a portion of the tax revenue is used to support cer- the permission of the house owners or other tenants in tified addiction counsellors at mental health institutes the building, or subject to neighbourhood zoning laws. or community-based mental health and substance use disorders providers.111 Taxes levied on cannabis differ considerably One consideration in determining the taxes to be applied 109 Ibid. to cannabis products is that the total price including 110 See, for example, United States, Colorado State, Joint Budget Committee, Appropriations Report Fiscal Year 2019–20 (June 2019); 108 Rachel A. Barry and Stanton A. Glantz, “Marijuana regulatory frame- Northwest High Intensity Drug Trafficking Area, Washington State: works in four US States: an analysis against a public health standard”, Marijuana Impact Report, vol. 2 (August 2017). American Journal of Public Health, vol. 108, No. 7 (July 2018), pp. 111 United States, State of Colorado, Joint Budget Committee, Appropria- 40 914–923. tions Report Fiscal Year 2019-20. On the basis of these considerations, all states have put Product proliferation 3 together a structure of taxation and revenue collection With regard to cannabis products and pricing in states from the cultivation, production and sale of cannabis. that have implemented measures for the non-medical use Current ad valorem state tax rates for cannabis range of cannabis, there has been a proliferation of products 112 from about 10 to 37 per cent across states. Local juris- that include cannabis flower, pre-rolled , vaporiz- dictions can also impose their own local taxes on the ers (vaping cannabis), concentrates and edibles such as sale of cannabis. California has two sets of excise taxes: candies and cakes, and a variety of beverages such as the first is a cultivation tax of $9.65 per ounce of dried soda drinks. The potency of those products varies across cannabis flower, $2.87 per ounce of dried cannabis leaves states, and while many states have facilities for monitor- and $1.35 per ounce of fresh cannabis plant; the second ing potency, the increasing potency of cannabis products, is a 15 per cent retail excise tax on any cannabis product in particular products other than those made from can- 113 sold. Paradoxically, illicit sales of cannabis currently nabis flower, may be a public health concern. A public play a much bigger role in the cannabis market of Cal- health-oriented best practices approach would include ifornia than is the case with typical tobacco markets. measures for limiting the potency of products in the As research shows, tobacco taxes raise tobacco prices interest of public health. For example, in Colorado, the and, notwithstanding illicit tobacco trafficking, thereby average percentage of Δ-9-THC in cannabis concentrates reduce the affordability of, access to and use of tobacco in 2017 was 69 per cent, with some stores advertising among adolescents and youth. By contrast, in the case up to 95 per cent of Δ-9-THC content in some products. of cannabis, despite relatively high tax rates on the legal In 2017, cannabis flower had an average of 19.6 per cent market, it is likely that cannabis products on the illicit Δ-9-THC content per gram, while overall, 92.9 per cent market will remain accessible to adolescents and youth of all products sold in retail cannabis stores in Colorado 114 in California. had more than 15 per cent of Δ-9-THC content.116

Advertising of cannabis products In California, the state has neither limited the potency All states in which the use of cannabis is legalized have of cannabis products, as products with Δ-9-THC content some degree of restriction on the advertising of can- of up to 90 per cent or more are allowed, nor limited the nabis products. For example, in California, advertising manufacturing or sale of flavoured products, such as can be directed only at people aged 21 and older, there flavoured vaping liquids, pre-rolled cigarettes or canna- are restrictions on false claims of health benefits, and bis-infused sodas that mimic “alcopops”, although state product labels cannot be appealing to children. In Colo- regulations have put in place restrictions on products rado, advertising is restricted to media with audiences resembling existing foods or with characteristics that of which no more than 30 per cent are under the age of are particularly attractive to children.117 However, in Sep- 21. In some states, such as Washington, advertisements tember 2020, the State Governor signed a bill by which cannot depict cartoon characters or contain pictures a certificate of analysis will be required for edible canna- that could be appealing to children. Moreover, public bis products to guarantee that the number of milligrams education messages about cannabis in many states seem of Δ-9-THC per serving does not exceed 10 mg, plus or

to mirror alcohol and tobacco control programmes that minus 12 per cent until 1 January 2022 and plus or minus the non-medical usecannabis of regulating in measures Developments CANNABIS | are primarily aimed at reducing risky and harmful or abu- 10 per cent after January 2022.118 sive use among vulnerable populations, such as children, pregnant women and problematic users.115

116 United States, Colorado Department of Public Health and Environ- ment, THC Concentration in Colorado Marijuana: Health Effects and 112 See table at the end of this chapter for details of taxation in each Public Health Concerns (July 2020). state. 117 Lynn D. Silver, Amanda Z. Naprawa and Alisa A. Padon, “Assessment 113 Gabriel Petek, “? Adjusting California’s cannabis taxes”, of incorporation of lessons from tobacco control in city and county Legislative Analyst’s Office report (December 2019). laws regulating legal marijuana in California”, Journal of American 114 Ibid. Medical Association (JAMA) Network Open, vol 3, No. 6 (June 2020). 115 Barry and Glantz, “Marijuana regulatory frameworks in four US 118 Jennifer McGrath, “California cannabis bills introduced in the 2021 States: an analysis against a public health standard”. California legislature”. 41 Table 1 Regulations for the legalization of the non-medical use of cannabis in Canada

Federal law Alberta

Legal process Government legislation

Gaming, Liquor and Cannabis Act Cannabis control and licensing Act Safe and Responsible Retailing of Title Cannabis Act and Cannabis Regulations and Gaming, Liquor and Cannabis (CCLA) Cannabis Act regulation Cannabis distribution Act (CDA)

Date implemented 17-Oct-18

Liquor, Gaming and Cannabis Alberta Gaming Liquor and Liquor and cannabis regulation Authority of Manitoba (LGCA) Regulatory authority Health Canada Cannabis (AGLC) branch Manitoba Liquor and Lotteries (MBLL)

Minimum age 18 19 19 19

30 g dried or equivalent i.e., 150 g of fresh cannabis 450 g of edible product Personal public 2,100 g of liquid product 30 g or equivalent 30 g or equivalent 30 g or equivalent possession limit 7.5 g of concentrates (solid or liquid)

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 30 cannabis plant seeds 4 cannabis plants not budding or flowering

Grow 4 cannabis plants per residence for personal use. Home cultivation Prepare cannabis products such as food and drink at home Maximum 4 plants Maximum 4 plants Maximum 4 plants if organic are not used.

Interpersonal sharing 30 g or equivalent of legal cannabis product

Retail transaction limit 30 g or equivalent

Dried cannabis/fresh cannabis: No THC or THCA can be added to dried or fresh cannabis products. Dried cannabis to be consumed by must not exceed 1 g in each discrete unit of cannabis product. Edible cannabis: 10 mg of THC per package. Cannabis extract (for ingestion or nasal, rectal or vaginal use): 10 mg of THC per unit (such as a capsule) Maximum or dispensed amount, 1000 mg of THC per package THC content (for ). Cannabis topical (for applying externally): 1000 mg of THC per package. Products intended to be “administered orally, rectally, vaginally or topically” must not exceed a maximum yield quantity of 10 mg of THC. Cannabis oil must not exceed a maximum yield of 30 mg of THC per ml of the oil

Federal processing licence is required in order to produce cannabis products and to package and label these Commercial products for sale to consumers via authorized distributors production and retailers. Licensed producers. Each province has an Excise stamp that needs to be fixed on the cannabis products.

Private and provincial retail stores, Licensed retailers. Commercial online sales. Private retail stores and online Private retail stores, provincial distribution Retail licensing regime similar sales. online sales. as for liquor.

42 Federal law Alberta British Columbia Manitoba 3

Cannabis edible products and concentrates legal for sale October 2019. Edible cannabis products must be shelf-stable and can only contain food and food additives as ingredients. If any components have a pH> 4.6 and activity> 0.85, they must not be packaged in hermetically sealed containers. • Edible cannabis must not contain meat, poultry or fish products as ingredients unless they are dried products produced and have a water activity equal to or less than Restrictions 0.85 at room . on edibles • Edible cannabis products must not contain any food, or fortification, poisonous or harmful substances, or anything considered unsafe that would cause the sale of a food to be prohibited under the Food and Drugs Act. • , ethyl alcohol and are prohibited additives except for ingredients with naturally occurring caffeine provided the total amount of caffeine per package does not exceed 30 mg, and ethyl alcohol that does not exceed 0.5% weight by weight.

No promotion, packaging or labelling that could be considered No promotion, packaging or labelling that could be appealing to young people, and Advertising considered appealing to young people, and ensuring that ensuring that important product Same as Federal Law important product information is presented clearly. information is presented clearly. legalization for Regulations | CANNABAIS Advertising allowed inside cannabis stores.

Flower: $ 0.75/g plus 16.8% of base amount Flower $0.25/g Trim: $0.225/g plus 17.8% Flower $0.75/g Taxation Cannabis Trim $0.75/g of base amount Trim $0.22/g Wholesale mark-up on non-medical excise duty rates in Seed $0.25/seed Seed: $0.75/seed plus 16.8% Seed and seedling: $0.75/seed or cannabis, a $0.75/g mark-up plus provinces and territo- Seedling $0.25/seedling of base amount seedling 9% per cent mark-up applied on ries (Department of Federal Ad Valorem Rate 2.5% of dutiable amount of Ad Valorem Additional Rate 7.5% 7.5% provincial sale tax in addition top of the $0.75/g Finance, Canada) cannabis product when delivered to purchaser plus 16.8% of deductible amount to Federal taxes when delivered (total applicable rate 24.3%)

In cars, areas frequented by In cars, areas frequented by Smoking and vaping cannabis is Provinces and territories can tailor rules in their Restrictions on use children, or tobacco-restricted children, or tobacco restricted illegal in public places (including own jurisdictions. areas. areas. enclosed public places).

43 New Foundland and Labrador Northwest Territories

Legal process

Cannabis Control Act Newfoundland and Labrador Cannabis Regulations Cannabis Legalization and Regulation Implementation Title Cannabis Management Corporation Act Control and Sale of Cannabis Act Act

Date implemented

North West Territories Liquor & Cannabis Commission Regulatory authority Cannabis Management Corporation Newfoundland and Labrador Liquor Corporation (NLC) (NTLCC)

Minimum age 19 19 19 Personal possession 30 g or equivalent 30 g or equivalent 30 g or equivalent quantity

Can grow up to 4 plants at primary residence. Plants must be kept in a separate locked space. Home cultivation Maximum 4 plants in a private dwelling Maximum 4 plants Outdoor plants must be located behind a locked enclosure at least 1.52 m in height. WORLD DRUG REPORT 2021 REPORT DRUG WORLD Interpersonal sharing

Retail transaction limit

Maximum THC content

Commercial production

Commercial Cannabis NB retail stores and online sales. Private retail stores, provincial online sales. NWT Liquor Stores, provincial online sales. distribution

Restrictions on edibles

Advertising

Taxation Flower: $0.75/g Flower: $0.75/g Flower: $0.75/g Cannabis excise duty Trim:$0.225/g Trim:$0.225/g Trim:$0.225/g rates in provinces and Seed/seedlings $0.75 Seed/seedlings $0.75 Seed/seedlings $0.75 territories (Department 7.5% of the dutiable amount when delivered 7.5% of the dutiable amount when delivered 7.5% of the dutiable amount when delivered of Finance, Canada) to purchaser to purchaser to purchaser

Illegal to everywhere except private Illegal to smoke everywhere except private Illegal to smoke everywhere except private Restrictions on use or residence. property or residence. property or residence.

44 Nunavut Ontario 3 Legal process

Cannabis, Smoke-Free Ontario, and Road Safety Statute Cannabis Act Title Cannabis Control Act Law Amendment Act, 2017 Cannabis Statutes Amendments Act Cannabis Statute Law Amendment Act, 2018

Date implemented

Regulatory authority Nova Scotia Liquor Corporation Nunavut Liquor and Cannabis Commission Alcohol and Gaming Commission of Ontario

Minimum age 19 19 19 Personal possession 30 g or equivalent 30 g or equivalent 30 g or equivalent quantity

Home cultivation Maximum 4 plants Maximum 4 plants Maximum 4 plants

Interpersonal sharing

Retail transaction limit

Maximum THC content

Commercial production

Commercial Currently through government-operated online store Designated NSLC stores or online. Government retail stores and online sales. distribution or by phone. Regulations for legalization for Regulations | CANNABAIS

Restrictions Sale of edibles illegal under Federal law. on edibles Edibles can be produced at home for personal use.

Advertising

Flower: $0.75/g plus 19.3% of base amount Flower: $0.75/g plus 3.9% of base amount Taxation Flower: $0.75/g Trim: $0.225/g plus 19.3% of base amount Trim: $0.225/g plus 19.3% of base amount Cannabis excise duty Trim: $0.225/g Seed/seedling: $0.75 seed plus 19.3% of base amount Seed/seedling: $0.75 seed plus 19.3% of base amount rates in provinces and Seed/seedlings $0.75 7.5% plus 19.3% of the dutiable amount of a cannabis 7.5% plus 19.3 % of the dutiable amount of a cannabis territories (Department 7.5 % of the dutiable amount when delivered to pur- product when delivered to a purchaser (total applicable product when delivered to a purchaser (total applicable of Finance, Canada) chaser rate of 26.8%) rate of 26.8 %)

Illegal everywhere except for areas where tobacco may Illegal everywhere except for areas where tobacco may Restrictions on use Illegal to smoke everywhere except private property. be smoked. be smoked.

45 Quebec Saskatchewan Yukon

Legal process

Cannabis Regulation Act The cannabis control (Saskatchewan) Act Cannabis Control Act Title Act to constitute the Société québécoise The cannabis control (Saskatchewan) Cannabis control and regulation act Cannabis Management Corporation Act du cannabis regulations

Date implemented

Cannabis Authority Provincial cannabis committee Yukon Liquor Corporation Regulatory authority Société québécoise du cannabis under the Saskatchewan Liquor and Cannabis management corporation Cannabis Licensing Board (2019) Gaming Authority

Minimum age 19 21 19 19 Personal possession 30 g or equivalent 30 g or equivalent 30 g or equivalent 30 g or equivalent quantity

Home cultivation Maximum 4 plants Maximum 4 plants Maximum 4 plants Maximum 4 plants

Interpersonal sharing

30 g per visit at Société québécoise du WORLD DRUG REPORT 2021 REPORT DRUG WORLD Retail transaction limit 30 g per purchase cannabis

Maximum THC content

Commercial production Licensed producers

Government retail stores and online Commercial Four dedicated government-owned retail Government retail stores and online Private retail stores, provincial online sales. distribution stores and online sales. sales. sales. Cannabis Yukon retail store.

Restrictions on edibles

Advertising

Flower: $0.75/g plus 6.45% of base amount Trim: $0.225/g plus 6.45% Taxation Flower: $0.75/g Flower: $0.75/g Flower: $0.75/g of base amount Cannabis excise duty Trim: $0.225/g Trim: $0.225/g Trim: $0.225/g Seed/seedling: $0.75 seed plus 6.45% of rates in provinces and Seed/seedlings $0.75 Seed/seedlings $0.75 Seed/seedlings $0.75 base amount territories (Department 7.5 % of the dutiable amount when 7.5 % of the dutiable amount when 7.5% of the dutiable amount when 7.5% plus 6.45 per cent of the dutiable of Finance, Canada) delivered to purchaser delivered to purchaser delivered to purchaser amount of a cannabis product when delivered to a purchaser (total applicable rate of 13.95%)

Illegal to smoke everywhere except for Illegal to smoke everywhere except areas where tobacco may be smoked, Illegal to smoke everywhere except Illegal to smoke everywhere except Restrictions on use private property, some exceptions for excluding university and CEGEP private property or residence. private property or residence. certain public spaces. campuses.

46 Table 2 Regulations for the legalization of the non-medical use of cannabis in jurisdictions in the United States 3 Alaska Arizona California Colorado

Voter , amendment to state Legal process Voter initiative, state statute Voter initiative Voter initiative constitution Title Ballot Measure 2 Proposition 207 Proposition 64 Amendment 64

Date passed Nov-14 Dec-20 Nov-16 Nov-12

DHS to accept licences from early applicants from 19 January 2021 to 9 Date implemented/ February 2015: Personal possession, December 2012: Personal possession, March 2021. required date of rule consumption, cultivation. October 2016: Licences issued 11 January 2018 consumption, cultivation. January 2014: Allow for cannabis deliveries beginning adoption Retail sales. Retail sales. sometime between 1 January 2023 and 1 January 2025.

Marijuana Enforcement Division Regulatory authority Alcohol and Marijuana Control Office Arizona Department of Health Services Bureau of Marijuana Control (Department of Revenue)

Minimum age 21 21 21 21

Residency requirement None None Licences not issued to non-residents None

Personal possession 28.5 g (1 oz or less) of cannabis or 5 g or 28.5 g of cannabis, or 4 g of concentrated 28.5 g (1 oz or less) 28.5 g limit less of concentrate cannabis

Plant, cultivate, harvest, dry, or process plants in accordance with local ordinances: Regulations for legalization for Regulations | CANNABAIS plants are in a locked space, and are not visible by normal unaided vision from a Six plants, three of which can be Six plants, three of which can be public place: flowering; from 1 January 2018, all flowering; not subject to public view; Six plants, as long as cultivation takes six living plants may be planted, cultivated, residences are limited to a maximum of 12 Home within property with lawful possession or place within an enclosed area with a lock harvested, dried, or processed within a plants unless certain requirements are cultivation with consent of the person in lawful pos- and is not visible from public view. single private residence; met; grow area must be enclosed and session. living plants and any cannabis produced locked in a separate space that minors by the plants in excess of 28.5 g are kept cannot access. within the person’s private residence, or upon the grounds of that private residence.

Yes, same as personal possession limits Interpersonal sharing 28.5 g Yes 28.5 g plus six plants 28.5 g In addition, a store may not sell in a day: (1) more than 1 oz of usable cannabis; Retail transaction (2) more than 7 g of Presumably same limits for personal Not specified Residents: 28.5 g Non-residents: 7 g limit for inhalation; or possession (3) more than 5,600 mg of THC in com- bined sales of marijuana and cannabis products.

Retail pricing structure Market Market/commercial Market/commercial Market

(1) for a single serving of a cannabis product, 5 mg of active tetrahydro- The potency of edible cannabis products (THC) or Delta 9 THC; are to be kept "at reasonable levels upon (2) in a single packaged unit of a cannabis Standardized concentration of cannabi- Maximum consideration of industry standards", but product to be eaten or swallowed, not noids not to exceed 10 mg tetrahydrocan- Not set THC content no more than 10 mg of THC per serving, more than 10 servings or 50 mg of active nabinol (THC) per serving. 100 mg of THC per package, or packages THC or Delta 9; the THC content must be with scored servings within the limits. homogenous, or evenly distributed throughout the cannabis-infused product.

Registration None None Not specified None requirements 47 Alaska Arizona California Colorado

Licensed cultivators and manufacturers, Commercial production Licensed cannabis producers Licensed producers Licensed cannabis cultivation facilities varying types Licensed stores with limitations; for example, one cannabis establishment licence per 10 pharmacies; Commercial Licensed retail cannabis stores or no more than two cannabis establish- Limits on market concentration Licensed retail cannabis stores distribution ment licences in counties that contain no registered non-profit medical cannabis dispensaries.

Maximum of 10 mg of THC in each individually packed serving; warning 5 mg of THC for single serving, no more labels "keep out of reach of children"; The potency of edible cannabis products than 50 mg of homogenous THC allowed 10 mg THC per serving. Warning and THC symbol on labels and not attractive Restrictions are to be kept "at reasonable levels upon per package. Child-resistant packaging potency labels. List of ingredients and to children. on edibles consideration of industry standards" (see required. Separate warnings on risks, not cannabinoid content. Every single standardized serving (10 mg above). appealing to children. of THC) of an edible retail cannabis prod- uct must be individually marked, stamped or imprinted with the universal symbol.

Logo or advertisement for licensed Prohibits the advertisement of cannabis

WORLD DRUG REPORT 2021 REPORT DRUG WORLD marijuana may not promote excessive products to children and prohibits Restricted to those over 21. Restrictions consumption, depiction appealing to the advertisement or sale of cannabis on false advertisement or claims of Restricted to media with no more than Advertising a person under 21 years of age. products with names that resemble or untrue health benefits. Products cannot 30% of the audience under the age of 21. Restrictions on advertisements in school imitate food or drink brands marketed appeal to children. areas, public transport, and contain pre- to children. scribed warning.

$50 excise tax per oz on sales or transfers from cultivation facility to retail store or 15% excise on retail, $9.25 per dry Excise tax of 16% on price of cannabis State sales tax (2.9%) on cannabis sold in product manufacturer; 1 January 2019, weight ounce on flower after harvest. and cannabis products. stores; state retail cannabis sales tax sales and transfers of marijuana are sub- $2.75 per drug weight ounce on leaves. Cannabis products are also subject to (15%) on retail cannabis sold in stores; Taxation ject to new tax rates. Mature bud/flower Tax rates for cannabis leaves to be transaction privilege tax which in 2020 state retail cannabis excise tax (15%) on are taxed at $50 per oz; immature or adjusted annually to reflect fluctuations was 5.6% – different jurisdictions also wholesale sales/transfers of retail canna- abnormal bud is taxed at $25 per oz; trim in the relative price of cannabis levy TPT retail taxes. bis. is taxed at $15 per oz; and clones are to cannabis leaves. taxed at a flat rate of $1 per clone.

In-store consumption is allowed; stores can sell cannabis and cannabis products, excluding concentrates, to patrons for Not specified although they may exists in On site consumption consumption on the licensed premises at Not specified the form of microbusiness that allow Not allowed the time of purchase only in a designated on-site consumption. area with further conditions stipulated in the regulation. Prohibit cannabis use in a public place Cannabis use in public is unlawful; viola- is illegal in public unlicensed for such use, including near Restrictions on use Not permitted in public places tion punishable by a fine of up to $100. places and open spaces. schools and other areas where children are present. 2010: adult patients and those under 18. For patients under 18, the patient's cus- todial parent or legal guardian must be 1998: Patient registry with a card, no designated as his/her caregiver. Patients dispensaries registration; out-of-state require a qualifying patient card which is 1996 and 2003; Patient registry - 2000: Patient registry, dispensaries patients recognized for approved based on diagnosis with one of the debili- voluntary registration; cooperatives and already existed; out-of-state patients not Medical cannabis conditions but not for pur- tating medical conditions, and a written collectives; State-wide licensing of dis- recognized; possession, consumption; chases; adults over 21 may also purchase certification from a (medical pensaries began 2018. 2010: commercial production and sales. at retail adult dispensaries. doctor, osteopath, naturopath, or homeo- path licensed to practice in Arizona) with whom the person has a physician-patient relationship.

48 District of Columbia Maine 3 Voter initiative Legal process Voter initiative Approved by legislature in May 2019 June 27, 2019, Governor signed into law 129th LD 719

Bill HB 1438 Question 1 Title Initiative 71 (Public Act 101-0027) (H.P. 1199 - L.D. 1719)

Date passed Nov-14 Signed by Governor 25 June 2019 Nov-16

Take effect on 7 January 2017; regulation for business to be in place August 2017. Date implemented/ February 2015: Personal possession, consumption, On 27 January 2017 the legislature approved a required date of rule Effective 1 January 2020 cultivation. moratorium on implementing parts of the law regarding adoption retail sales and taxation until at least February 2018. Law finally took effect on 19 September 2019.

Not applicable; considering separate legislation to Department of Administrative and Financial Services Regulatory authority Department of regulate commercial production and sale to adults. (Office of Marijuana Policy)

Minimum age 21 21 21

Residency requirement None Partially required Not specified

30 g of cannabis flower; no more than 500 mg of THC Personal possession contained in cannabis infused product; 5 g of cannabis 71.25 g (2.5 oz) 2 oz (57 g) quantity concentrate. Concentrates up to 5 g Half of these amounts allowed for non-residents Regulations for legalization for Regulations | CANNABAIS Cultivation is allowed for qualifying persons under "Compassionate Use of Medical Cannabis Pilot Pro- gramme Act" Three flowering marijuana plants, 12 immature plants Plants, with a limit of 5five plants that are more and unlimited seedlings. An adult may possess all of the than 5 inches tall, per household without a cultivation cannabis produced by the plants. Property owners can centre or craft grower licence. prohibit home cultivation. Six plants per person; Home Cannabis cultivation must take place in an enclosed, Cultivation for medical purposes not subject to same 12 plants per household, ultivation locked space. restrictions. six of which can be flowering. Adult registered qualifying patients may purchase Plants must be tagged with the cultivator’s name, driver’s cannabis seeds from a dispensary for the purpose of licence or ID number, and — if the plants are not on land home cultivation. Seeds may not be given or sold to any owned by the cultivator — the name of the property other person. owner. Cannabis plants shall not be stored or placed in a location where they are subject to ordinary public view.

Same as personal possession limits; in addition no more Interpersonal sharing 28.5 gm or less (transfer without payment) than six seedlings or immature plants;

Retail transaction limit Not applicable Not applicable 28.5 g (1 oz); 12 seedlings

Retail pricing structure No retail market Market Market/commercial

Initially 100 mg of THC per package; Department of Agri- culture may change maximum level of THC contained in Maximum each serving of cannabis infused product. Not set initially Not set except for edibles THC content Allow possession of cannabis-infused products such as capsules, consumables, , and other edibles that contain no more than 500 mg of THC.

Registration Non-residents are allowed half the amounts allowed for None Not specified requirements residents

Licensed cultivators and craft growers (who cultivate, dry, Commercial production None Licensed cultivators; two types based on size and package cannabis for sale)

State authority may not limit total number of stores; Commercial Licensed dispensers both for medical and None localities may regulate number and location of estab- distribution non-medical use lishments. 49 District of Columbia Illinois Maine

Edibles may not contain more than 10 mg of THC per Restrictions Allowed but with information and warning Currently not allowed serving of the product and may not contain more than on edibles on consumption 100 mg of THC per package of the product.

Businesses cannot place advertisements that have false or misleading claims; or advertisements that promote overconsumption; depict actual consumption; depict a person under 21 consuming; make health, medicinal or therapeutic claims; contain images that can be appeal- Restricted to those over 21. Restrictions on false adver- Advertising Not applicable, no commercial market ing to minors or children; advertisements are not tisement or claims of untrue health benefits. Products allowed within 1,000 feet of school or playground, cannot appeal to children. public park or library, public transport or public prop- erty; no sales promotions are allowed; similar restric- tions apply on packaging and labelling. Health warnings to be legibly displayed.

10% sales tax on cannabis flower or products with less than 35% THC; 20% tax on cannabis-infused products such as edibles; 25% tax on products with a THC concentration higher 10% excise tax on retail;

WORLD DRUG REPORT 2021 REPORT DRUG WORLD than 35%; Taxation Not applicable, no commercial market 15% excise tax on sale or transfer from a licensed Illinois municipalities and counties are able to levy addi- commercial cultivation to licensed retail store. tional local sales taxes. 6.25% State Retailers' Occupation Tax; Consumers may pay between 19.55% and 34.75% depending on a product's potency.

Not allowed; currently under investigation by Local jurisdictions and retail outlets may or may not On site consumption State-licensed clubs city task force. allow; designated cannabis-centred businesses lounges.

Not permitted in public places (allowed use in private Smoking cannabis is not allowed in any place where Restrictions on use Not permitted in public places (use on private property) property or smoking in a state-licensed marijuana smoking is prohibited under the Smoke Free Illinois Act. social club).

Compassionate use of medical cannabis pilot programme act, August 2013. Eligible patients with a doctor's recommendation, with a recognized debilitating condition, after registering with 1999: Patient registry or identification card; the state, may legally consume medical marijuana. Medical cannabis 1998/2010: Patient registry; dispensaries allowed. dispensaries, recognizes patients from other states but Purchase limit is 2.5 oz of cannabis flower every not for dispensary purchases. 14 days. New law also allows school nurses or adminis- trators to give cannabis products to students who are registered medical patients and permits students to medicate under the supervision of those officials

50 Massachusetts Michigan Montana Nevada New Jersey New Mexico 3 Legal process Voter initiative Voter initiative Voter initiative Voter initiative Voter initiative Legislative process

Question 1 New Jersey Cannabis Question 2 HB 2 Cannabis Question 4 Regulatory, Enforcement Title Proposal 18-1 Initiative 190 Title 56 Nevada Revised regulation act passed by Mass. General Laws c.94G Assistance, and Market- Statutes 678 legislature 31 March 2021 place Modernization Act (A-21 (P.L.2021,c.16)

Date passed Nov-16 6 December 2018 November 2020 Nov-16 Nov-20 Mar-21

15 September 2017. Takes effect on 1 January The Cannabis Act was Date implemented/ Licences issued starting Commercial licences 2017 and regulations to be Signed by governor on 12 Application for licensure signed on 22 February 2021 required date of rule 1 October 2017. application began by in place by 1 January 2018. April 2021. Sales to begin in by 1 January 2022. and went into immediate adoption Law updated on 20 June, 6 December 2019. Cannabis regulation 2022. effect. 2019. effective 1 July 2020.

1) Cannabis Control Cannabis Control Division Marijuana Regulatory Cannabis Compliance Cannabis Regulatory Regulatory authority Commission and Cannabis Department of Revenue to be established by Agency Board Commission Advisory Board September 2021

Minimum age 21 21 21 21 21 21

Residency requirement Not specified Not specified Not specified None None

56 g (2 oz) 1 oz flower (28.5 g) 28.5 g (1 oz) flower

Personal possession 2.5 oz (70.8 g) on person 28.5 g (1 oz) or 8 g in 28.5 g (1 oz) of cannabis 16 g of cannabis legalization for Regulations | CANNABAIS 5g concentrate or 10 oz at 1/8 oz or 3.5 g limit and 10 oz (283 g) at home concentrated form or its equivalent concentrates and 800 mg home concentrate or edible of infused edibles

6 plants, no more than 12 4 mature plants and 4 seed- 6 plants, 12 in a single on property in indoor or in Up to 12 plants per house- lings; not visible from a 6 plants per person, or 12 Home residence away from view; enclosed with permission of Home cultivation is hold not visible from a public place; not more than per household; away from cultivation 10 oz of dried marijuana landlord and must be 25 prohibited at the moment. public place. twice the number to be public view. permitted at home. miles away from retail kept on the grounds. cannabis store.

2.5 oz with a max of 15 mg Less than twice the amount Interpersonal of concentrate as long as of personal possession limit Same as personal Yes Yes Not yet sharing money is not exchanged. without any consideration possession limits. or remuneration.

Not specified, presumably Not specified, presumably Not specified, presumably To be determined - Same as personal Retail transaction limit same limits as for personal same limits as for personal Not specified same limits as for personal expected to be the same as possession limits. possession. possession. possession. personal possession limits.

Market/commercial when Regulated market, expected Retail pricing structure Market/commercial Market/commercial Market/commercial Market/commercial developed to start in 2022

Maximum THC content Not set initially Not set Not specified Not set initially Not set Not specified

Registration Personal data collection not Personal data collection not None None None None requirements required required

Licensed cultivation/ production. Commercial production Licensed establishments Licensed establishments Licensed Licensed establishment Licensed Small cannabis micro- businesses can grow up to 200 plants.

Licensed establishments; A municipality may Commercial localities can regulate, completely prohibit or Limits on market concen- Licensed Licensed establishments Licensed distribution limit or prohibit the opera- limit the number of tration by population tion of businesses. establishments operating. 51 Massachusetts Michigan Montana Nevada New Jersey New Mexico

Cannabis infused products Single-serving edible can- Serving size and potency may not be in shapes or Edible cannabis product nabis product offered for Restrictions limits to be developed in packages that are attrac- shall contain no more than Not specified sale to a consumer con- Not specified on edibles regulations. List of ingredi- tive to children or that are 10 mg of active THC per taining not more than 10 ents. easily confused with com- unit of sale. mg of THC. mercially sold candy.

Restrict advertising of cannabis items and cannabis 41 paraphernalia in ways that target or are Advertising cannabis A licensed marijuana designed to appeal to to people under 21 is pro- establishment cannot individuals under the legal hibited, with the use of engage in advertising that age to purchase cannabis cartoon characters or contains any false or mis- items includes objects, other imagery likely to Restrictions on marketing Restrictions on public Advertising cannabis is leading statements, pro- such as toys, characters, appeal to children forbid- Advertising to children to be devel- signs related to cannabis prohibited in any medium motes overconsumption, or cartoon characters den. Advertisements will oped in regulations. establishments. including electronic media. depicts actual consump- suggesting the presence of also be barred from bill- tion, or appeals to minors. a person under 21 years of boards or other public Also applies 70/30 rule age or any other depiction; media within 300 feet of a

WORLD DRUG REPORT 2021 REPORT DRUG WORLD from Colorado. also advertising on televi- school, day-care centre or sion and radio between church 6:00 to 22:00 is prohibited; also prohibited to sponsor sports or cultural events.

General state sales rate of 6.625%; Annually adjusted excise fee based on average retail price: up to $10 per oz if the 10.75% excise tax on average retail price of an retail sales. ounce was $350 or more; 6.25% state sales tax 15% excise on wholesale 12% excise tax to be up to $30 per oz if the applies to retail purchases sale. gradually increased to 18% Taxation 10% excise tax 20% of the retail price average retail price of an of all cannabis products. 10% excise tax on retail by 2030; plus 8% regular ounce was less than $350 Up to 3% local excise tax, sale. state sales tax. but at least $250; optional, on retail pur- up to $40 per oz if the chases of all products. average retail price of an ounce was less than $250 but at least $200; and up to $60 per oz if the average retail price of an ounce was less than $200.

Not allowed, although they may exist in establish- Is allowed if businesses On site consumption Not specified Not specified Not specified Not specified ments that allow offer on-site-consumption.

Not permitted in public places or places where Cannabis consumption is prohibited by person who Not permitted in public Public consumption for private use only. It is Cannot use cannabis in a owns, occupies or man- places where smoking Consumption is only per- remains illegal, but busi- illegal to smoke in public, Restrictions on use place where smoking ages the property, allowed tobacco is prohibited, mitted in a private resi- ness can offer on-site con- on federal land or in a tobacco is prohibited in designated public places unless allowed by the dence. sumption if certain vehicle without risking a that are not accessible to department. requirements are met. fine. persons under 21 years of 52 age. Massachusetts Michigan Montana Nevada New Jersey New Mexico 3

2009: Medical cannabis can be purchased from any state-licensed New Jersey cannabis dispensary. determine the 2008: patient registry, proper dosage allowed for 2007: In 2020, registered dispensaries can be 2000: Patient registry or the patient, with a patients are required to established with local identification card, No maximum set at 3 oz for a be state residents; patients 2012/2013; patient ordinances; dispensation 2004: Registered card dispensaries; recognize out 30-day period. Each is need to have a certifica- registry or identification Medical for specific conditions, holders; signed physician of state patients if other sold in 0.25 oz denomina- tion from a prescriber with cards; dispensaries, cannabis recognize out of state statement for a debilitat- state's programmes are tions. Visiting patients the qualifying conditions; out-of-state patients not patients only for legal pro- ing condition. substantially similar; with valid medical mari- patients are allowed to recognized. tection of possession but patients must fill out juana cards from their possess no more than 230 not for dispensary pur- Nevada paper work. home state are granted units (approx. 8 oz of chases. the same protections and flower or buds). allowances surrounding possession and consumption as New Jersey resident cardholders.

New York Oregon South Dakota Virginia Washington Regulations for legalization for Regulations | CANNABAIS Voter initiative, Voter initiative, Legal process Legislative process Voter initiative Legislative process Legislative state statute state statute

No. 86 SB 1406 Marijuana; legali- Assembly bill A1248 A S.54 (initiated in February zation of simple posses- Title Marijuana regulation and Measure 91 2020 and went into force sion Initiative 502 taxation act in October 2020 without Signed by governor on 7 the Governor's signature April 2021

Date passed March 31, 2021 Nov-14 Nov-20 Jan-18 Apr-21 Nov-12

July 2015: Personal Effective July 2021, Anticipated date of possession, consumption, Bill provisions are subject implementation was 1 Assembly bill signed by cultivation. October 2015 to re-enactment by the Date implemented/ April 2022. 1 July 2018 December 2012: Personal governor on 31 March up to December 2016: 2022 Session of the state required date of rule The ballot measure Sale regulations effective possession, consumption 2021; Sales may begin in Retail sales through General Assembly. adoption overturned by courts in October 2020 July 2014: Retail sales. December 2022. medical dispensaries Sales beginning and February 2021. January 2017: Retail sales regulations taking effect through licensed retailers. on 1 January 2024.

Virginia Cannabis Control Authority Cannabis Oversight Commission; Cannabis Public Health Liquor and Cannabis Board Regulatory Oregon Liquor Control Cannabis Control Board Cannabis Control Board Department of Revenue Advisory Council (formerly the Liquor authority Commission (proposed under S.54) Cannabis Equity Reinvest- Control Board) ment Board and Fund, and Virginia Cannabis Equity Business Loan Program and Fund

Minimum age 21 21 21 21 21 21

Residency requirement None None None None None None 53 New York Oregon South Dakota Vermont Virginia Washington

Personal possession 85.5 g (3 oz) or 24 g of In public: 28.5 g; 28.5 g (1 oz or less) or 8 g 28.5 (1 oz) or less or 5 g or 28.5 (1 oz) or less 28.5 g quantity concentrated cannabis At home: 228 g of concentrate less

Up to 4 plants for personal use per household. The 6 plants, 3 mature and 3 2 mature plants or 7 plants should be kept away Home cultivation seedlings, or up to 12 per 4 plants in flower. Not allowed immature plants. from public view, and each household. one should have a legible tag with owner's ID.

Same as personal Interpersonal 28.5 or 1 oz or less, or 5 g Yes, same as personal possession limits but 28.5 g Not allowed sharing or less limit. without compensation.

1 oz dried flower 16 oz edible form 72 oz cannabis in liquid 1 oz or cannabis 28.5 g (1 oz) Retail transaction limit To be determined. form or equivalent in cannabis 28.5 g or equivalent 10 cannabis seeds products

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 4 immature cannabis plants

Retail pricing structure Market/commercial Market Market Market with limitation Market

Flower is capped at 30% THC and concentrates Maximum cannot exceed 60% THC. Not set Not set initially Not specified Not set initially THC content Edibles have a 50mg limit per package, 5mg per serving.

Registration None None None None None requirements

Number of licences (proposed) not to exceed: Commercial Licensed cannabis a) Marijuana manufactur- Licensed cannabis Licensed Licensed production producers ing facilities, 60; and producers b) Marijuana cultivation facilities, 450

Licensed establishments. Number of licences Existing medical cannabis issued shall not exceed the operators will be allowed following limits: Cannabis can only be Commercial Licensed retail cannabis to operate three adult-use Licensed a) Retail marijuana stores, sold and purchased at distribution stores stores, co-locating them 400; state-licensed retail stores. with their medical b) Marijuana wholesalers, dispensaries. 25.

10 mg of THC in each indi- Maximum of 10 mg of Not to contain more than vidually packaged serving; THC in each individually 5 mg of THC per serving child-proof packaging; THC Restrictions packed serving; edible of the product; and shall labelling; marijuana-in- None None on edibles products to undergo a not contain more than 50 fused products, packages preapproval process; not mg of THC per package of and labels to be approved appealing to children. the product. by the State Liquor Control Board before sale. 54 New York Oregon South Dakota Vermont Virginia Washington 3

Cannabis business licensees are limited to two permanent signs on Advertising could not be their licensed premises, deceptive, promote over- and all other forms of Entry sign required on consumption, offer free outdoor ads on the The board is authorized exterior of dispensaries; samples, or be appealing Board to regulate reasona- premises are banned. to promulgate rules and Oregon Liquor Control to minors. Advertising ble restrictions on adver- New rules mandated that Advertising regulations governing the Commission has authority would only be allowed tising and promotion of billboards and signs can advertising to further regulate or pro- where the licensee can products. no longer contain images hibit advertising. reasonably expect no more of the cannabis plant or than 15% of viewers will cannabis products. Cannot be under 21. contain depictions of cartoon characters or any depictions that may be appealing to children.

Proposed tax is 13%. No tax on retail sales Wholesale tax will be from October 2015 to 37% cannabis excise tax; applied to products based December 2015; 25% sales Sales Tax: 7.0-10.4% on potency (0.5 cent per tax after 5 January 2016; 14% of sales price of retail Taxation 15% tax proposed 20% retail sale tax (Option to apply existing mg for flower, 8/10th of a 17% sales tax in 2017 sale local sales taxes (0.5- cent per mg for concen- with options for local 3.1%)). trated cannabis and 3 communities to establish cents per mg for edibles). local tax up to 3% . legalization for Regulations | CANNABAIS

On site consumption Is allowed Not allowed Maybe allowed Not specified Not allowed

Prohibited in public places other than in an area Use is limited to individual Smoking cannabis in any licensed by the Depart- dwellings. Prohibited in It is illegal to consume location is prohibited Smoking marijuana in Public use of cannabis will Restrictions on use ment for consumption; street, alley, park or side- cannabis in view of the where smoking tobacco is public is illegal. be prohibited. smoking in a location walk in addition to usual public. prohibited. where smoking tobacco is smoke free places. prohibited.

2014: Registration and ID card, medical cannabis 1999/2010/2011: Department of health to be given either to a 1998: Patient registry, no registration or reviews application certified patient (resident dispensaries already 2020: Registration is based identification card; of qualifying patients of the state) or by a existed but not clearly 2020: court ruled it on certification from a dispensaries approved as Medical cannabis diagnosed with qualifying designated caregiver for a authorized by law or unconstitutional. practitioner for specified of November 2012, first conditions; DoH verifies certified medical use for regulated; possession, conditions. stores opened in July 2014: the condition with the defined "severe debilitating home cultivation. 1999 possession 2012: physician. or life threatening Home cultivation. conditions.

55 Table 3 Regulations for the legalization of the non-medical use of cannabis in Uruguay

Uruguay

Legal process Government initiative, national law

Title Law No. 19.172

Date passed Dec-13

Date implemented/ August 2014: Personal cultivation October 2014: Grower clubs Mid-2017: sales required date of rule adoption

Regulatory authority Institute for the Regulation and Control of Cannabis (IRCCA)

Minimum age 18

Residency requirement Uruguayan citizenship or permanent Uruguayan residency required

Personal possession limit 40 g per month

Home cultivation Six plants in flower WORLD DRUG REPORT 2021 REPORT DRUG WORLD Interpersonal sharing Allowed within the home

Retail transaction limit 40 g per month, 10 g per week (sale through pharmacies to registered users)

Retail pricing structure Government price control

Average retail price per gram after tax 265 Uruguayan pesos per 5 g (approx. $1.2 per gram)

Maximum THC content All products are required to indicate that CBD is equal to or more than 3% and THC is equal to or less than 9%

Registration requirements Yes, with IRCCA for any of the three modes of access

Commercial production Licensed marijuana producers

Commercial distribution Licensed pharmacies

Restrictions on edibles

Advertising Prohibited

Taxation No tax, although IRCCA can impose tax in the future

Cannabis clubs Clubs with 15-45 members allowed to cultivate up to 99 plants, maximum 480 g of dried product per member per year

Restrictions on use

In 2013: Passed (Law 19.172). Decree N° 46/015. Oils under prescription (CBD) and with CBD currently for Medical cannabis sale in pharmacies.

56 OPIOIDS 3

synthetic opioids that are analogues of are Overlap between the use of opioids considered to be 50–100 times more potent than mor- phine.121, 122, 123 Research or NPS opioids such as U-47700, Opioids are a group of drugs comprising a range of sub- AH-7921, fentanyl analogues (, butyrylfen- stances, including opiates and their synthetic analogues. tanyl), the new class of ()124 Opiates are the naturally occurring found in the and the more recent ,125 to name but a few, have opium poppy and include , and the- added to the ever-increasing complexity of opioids, both baine. Their semi-synthetic derivatives include , in terms of controlling the misuse of these substances , and . Opioids and their public health implications. Many of the research also include a range of synthetic or pharmaceutical opioids, such as U-47700 or butyrylfentanyl, have been opioids, such as , , tramadol and put under international control in recent years, how- 119 fentanyl. ever. Moreover, some of the substances, such as W-15 and W-18, were initially introduced as potent opioids The group also comprises a diverse group of chemicals – but were later found to have no activity on the opioid opioid – that were initially developed receptors, although they were put under national con- by pharmaceutical companies with the aim of produc- trol in some countries.126 Nevertheless, research opioids ing more effective opioids for pain management, but are among the fastest increasing group among the wider were later discarded or considered unsuitable for further the useopioids of between Overlap OPIOIDS | new psychoactive substances identified or reported each development.120 Many of those substances, also known year.127, 128 as research opioids, novel synthetic opioids or NPS opi- oids, are considered to be more potent than morphine; Opioids act on three types of opioid receptors – mu (μ), delta (Δ) and kappa (Κ) – in the human body, through Fig. 37OPIOIDS Opioids FOR for MEDICAL medical and AND non-medical NON­MEDICAL purposes PURPOSES which they mediate their effects by: (a) depressing

OPIATES ETIC OP NTH IOID SY S 121 Gabriella Roda and others, “Ten years of fentanyl-like drugs: a techni- cal-analytical review”, Analytical Sciences, vol. 35, No. 5 (May 2019), pp. 479–491. 122 Clara Pérez-Mañá and others, “Drug interactions with new synthetic opioids”, Frontiers in , vol. 9, art. No. 1145 (October 2018). tramadol 123 Matthew P. Prekupec, Peter A. Mansky and Michael H. Baumann, “Misuse of novel synthetic opioids: a deadly new trend”, Journal of fentanyl and codeine, hydrocodone, its analogues , vol. 11, No. 4 (July/August 2017), pp. 256–265. heroin, morphine, , opium oxycodone, etc. 124 Peter Blanckaert and others, “Report on a novel emerging class of methadone, highly potent benzimidazole NPS opioids: chemical and in vitro pethidine, P research functional characterization of isotonitazene”, Drug Testing and H , UNDER A fentanyl, etc. opioids Analysis, vol. 12, No. 4 (April 2020), pp. 422–430. RM INTERNATIONAL A CEU 125 Nick Verougstraete and others, “First report on brorphine: the TICA CONTROL L OPIOIDS next opioid on the deadly new psychoactive substances’ horizon?”, Journal of Analytical , vol. 44, No. 9 (November 2020), pp. 937–946. 126 Xi-Ping Huang and others, “Fentanyl-related designer drugs W-18 and W-15 lack appreciable opioid activity in vitro and in vivo”, JCI Insight, Source: UNODC elaboration. vol. 2, No. 22 (November 2017). 127 UNODC, World Drug Report 2020, booklet 4, Cross- Issues: Evolving Trends and New Challenges (United Nations publication, 119 WHO, Lexicon of Alcohol and Drug Terms (Geneva, 1994). 2020). 120 See also UNODC, World Drug Report 2019, booklet 3, 128 Roda and others, “Ten years of fentanyl-like drugs: a technical (United Nations publication, 2019). analytical review”. 57 breathing through the neurochemical activity in the brain of heroin, there was significant substitution with phar- stem where automotive body functions such as breathing maceutical opioids and, to a lesser extent, substitution and are controlled; (b) increasing feelings of with and .134 Estonia by altering activity in the limbic system, which and Finland are two countries where, owing to a short- controls behavioural and emotional responses, such as age in the availability of heroin, two synthetic opioids, the regulation of stress responses, feeding, mood, learn- fentanyl (in the case of Estonia) and buprenorphine (in ing, memory and immune functions; and (c) blocking the case of Finland) have completely replaced heroin pain messages transmitted through the from and established themselves on the opioid market.135, 136 other parts of the body.129 The abuse liability of an opioid is essentially determined by many factors, including the There are essentially three different scenarios in the ease with which the opioid can cross the –brain interplay of the use of different opioids: (a) typically used barrier (lipophilicity of the drug), its binding affinity to opioids are substituted with other opioids, or new opioids opioid (mainly mu) receptors, and various pharmacoki- are experimented with, depending on their price, purity, netic characteristics such as the ease with which it can availability and control measures; (b) different opioids be injected or used with other means of administration are used consecutively or sequentially to self-medicate 137 (smoking or ).130 or manage withdrawal, including during opioid or antagonist138 ; and (c) opioid users (novice or Studies have shown that, in response to market dynam- even regular users) are inadvertently exposed to other WORLD DRUG REPORT 2021 REPORT DRUG WORLD ics, drug users may substitute different drugs, transition opioids used as or cutting agents for sub- to alternative routes of drug administration, decrease stances already established in the market. consumption or enter treatment. Overlap between or substitution of different opioids is not a new phenome- Switching between opioid use in response non and has been observed in different settings. Findings to market dynamics from different studies have consistently shown a positive association between the non-medical use of pharma- The first pattern of use that involves an overlap, or ceutical opioids and the use of opiates (heroin), given rather substitution, between different opioids is the the common pharmacological principles and actions of most common pattern of use of different opioids and has opioid substances.131 been observed for decades in different regions. Although pharmaceutical opioids and heroin have the potential to Along with the availability of the drugs, economic factors induce similar pharmacological mechanisms, as described and cross-price elasticity can affect the use of different earlier, some of their may differ. Thus, the opioids.132 An increase in the price of one drug may result choice of opioid is likely to be influenced by, among other in the consumption of another (substitute) or an increase factors, the balance between the subjective positive and in the price of one drug may decrease the consumption negative effects produced by a specific opioid. For exam- of another, even though its price remains the same ple, a study of heroin users in the United States showed (complement).133 In one study in Australia, for example, a cross-price elasticity analysis showed that, in the case 134 Jenny Chalmers, Deborah Bradford and Craig Jones, “The effect of methamphetamine and heroin price on : a behavioural economics analysis in , Australia”, International Journal of Drug 129 WHO, Neuroscience of Psychoactive Substance Use and Dependence Policy, vol. 21, No. 5 (September 2010), pp. 381–389. (Geneva, 2004). 135 EMCDDA, “Finland: Finland drug report 2018” (Helsinki, 2018). 130 Wilson M. Compton, Christopher M. Jones and Grant T. Baldwin, 136 Ilkka Ojanperä and others, “An epidemic of fatal 3-methylyfentanyl “Relationship between nonmedical prescription-opioid use and in Estonia”, International Journal of Legal Medicine, vol. 122, heroin use”, The New England Journal of Medicine, vol. 374 (2016), No. 5 (September 2008), pp. 395–400. pp. 154–163. 137 According to Lexicon of Alcohol and Drugs Terms, an agonist 131 Danielle Horyniak and others, “How do drug market changes affect is a substance that acts on neuronal receptors to produce effects characteristics of injecting initiation and subsequent patterns of drug similar to those of a reference drug. For example, methadone is an use? Findings from a cohort of regular heroin and methamphetamine agonist of morphine at the opioid receptors. injectors in Melbourne, Australia”, International Journal of Drug Policy, 138 According to the WHO Lexicon of Alcohol and Drugs Terms, an antago- vol. 26, No. 1 (January 2015), pp. 43–50. nist is a substance that counteracts the effects of another substance 132 Peter Caulkins and P. Reuter, “The meaning and utility of drug prices”, or agent. Pharmacologically, an antagonist interacts with a receptor Addiction, vol. 91, No. 9 (September 1996). to inhibit (counter or stop) the action of the substance that produces 133 Nancy M. Petry and Warren K. Bickel, “Polydrug abuse in heroin specific effects mediated by that receptor. Methadone is an opioid addicts: a behavioural economic analysis”, Addiction, vol. 93, No. 3 agonist, whereas buprenorphine is an agonist and partial antagonist 58 (March 1998), pp. 321–335. of opioid receptors. that the subjective reinforcing effects of oxycodone were have been part of the progression of addiction in a sub- similar to those produced by morphine or heroin, but group of users of pharmaceutical opioids for non-medical 3 without the unwanted or unpleasant effects reported by purposes who considered it too costly to maintain their the study participants.139 The authors concluded that the patterns of consumption and switched to heroin use as abuse liabilities of fentanyl, morphine, oxycodone and they considered the drug more reliably available through heroin appeared to be similar, under the experimental drug dealers, more potent and more cost-effective than conditions in which the study was conducted. pharmaceutical opioids. 142 In the United States, the opioid market has fluctuated In the United States over the period 2002–2013, the con- from the use of heroin to the non-medical use of phar- siderable increase in the use of heroin translated into an maceutical opioids, and currently to a dual epidemic of increase in the rate of past-year use of the drug, in par- heroin use and non-medical use of pharmaceutical opi- ticular among people who self-reported past-year use of oids. The non-medical use of pharmaceutical opioids in other substances, especially cocaine and pharmaceutical the country began to increase from 1997, at the same time opioids. Between the periods 2002–2004 and 2011–2013, as an increasing number of opioid prescriptions were heroin use increased by 139 per cent among those who being given for pain management, in particular chronic self-reported the non-medical use of pharmaceutical opi- non- management. Over the period 1997– oids.143 A study from 2007 among a sample of opioid users 2005, there was a more than 500 per cent increase in aged 16 and older in Maine, United States, concluded that the number of opioid prescriptions given, which resulted the use of multiple pharmaceutical opioids within the in easy access to diverted supplies of opioids, the use of first year of initiation of opioid use was associated with which was less stigmatized than of heroin.140 Pharmaceu- a more rapid progression to heroin and injecting drug tical opioids were considered safer than heroin, as they use than among those who were not misusing multiple did not carry the stigma of using an “illicit” drug and pharmaceutical opioids.144 Another study that looked

were less affected by fluctuations in quality or dosage. A at national data for 2002–2004 found that, among the the useopioids of between Overlap OPIOIDS | study of opioid users in treatment (2010–2013) reported population aged 18 and older, heroin users were 3.9 times that respondents who began using heroin in the more likely to report the non-medical use of opioids in were predominantly young men (83 per cent) and, in the the previous year and 2.9 times more likely to meet the majority (80 per cent) of cases, the first opioid they had criteria for abuse or dependence on opioids than people used was heroin. By contrast, opioid users in treatment who did not use heroin.145 who began using more opioids recently were older and In 2019, about 10 million people in the United States were men and women living in less urbanized areas (75 self-reported the non-medical use of opioids in the past per cent) who were introduced, in the majority of cases year: 9.3 million self-reported the non-medical use of (75 per cent), to opioids through pharmaceutical drugs.141 pharmaceutical opioids and 745,000 self-reported the Beginning in 2006, a gradual increase in heroin use use of heroin. About 400,000 people self-reported the was observed in parts of the United States, which was use of both heroin and non-medical pharmaceutical opi- attributed mainly to the availability of heroin that had oids.146 It should be noted that the national survey does a higher purity and was cheaper than in the past on the market and a change in the of pharmaceu- 142 Compton, Jones and Baldwin, “Relationship between nonmedical tical opioids to make them crushproof and less liable prescription-opioid use and heroin use”. to misuse. It has been hypothesized that the transition 143 Christopher Jones and others, “Vital signs: demographic and sub- from the non-medical use of pharmaceutical opioids to stance use trends among heroin users – United States, 2002–2013”, Morbidity and Mortality Weekly Report, vol. 64, No. 26 (July 2015). the use of heroin, especially among young people, could 144 Lauretta E. Grau and others, “Illicit use of opioids: is OxyContin a ‘gateway drug’?”, The American Journal on , vol. 16, No. 3 139 Sandra D. Comer and others, “Abuse liability of prescription opioids (May–June 2007), pp. 166–173. compared to heroin in morphine-maintained heroin abusers”, Neu- 145 William C. Becker and others, “Non-medical use, abuse and depend- ropsychopharmacology, vol. 33, No. 5 (April 2008), pp. 1179–1191. ence on prescription opioids among U.S. adults: psychiatric, medical 140 Sarah G. Mars and others, “Every ‘never’ I ever said came true: tran- and substance use correlates”, Drug and Alcohol Dependence, vol. 94, sitions from opioid pills to heroin injecting”, International Journal on Nos. 1–3 (2008), pp. 38–47. Drug Policy, vol. 25, No. 2 (March 2014), pp. 257–266. 146 United States, Substance Abuse and Mental Health Services Admin- 141 Theodore J. Cicero and others, “The changing face of heroin use in istration, Key Substance Use and Mental Health Indicators: Results from the United States: a retrospective analysis of the past 50 years”, JAMA the 2019 National Survey on Drug Use and Health (Rockville, Maryland, Psychiatry, vol. 71, No. 7 (July 2014), pp. 821–826. Center for Behavioral Health Statistics and Quality, 2020). 59 Fig. 38 Past-year non-medical use of pharmaceutical opioids and heroin, United States, 2019

. million people misused pharmaceutical opioids  , . million people people used heroin misused hydrocodone

. million people , misused oxycodone people used heroin only

, people misused fentanyl products (licit) people misused pharmaceutical opioids and used heroin

Source: United States, Substance Abuse and Mental Health Services Administration, Key Substance Use and Mental Health Indicators: Results from the 2019 National Survey on Drug Use and Health (Rockville, Maryland, Center for Behavioral Health Statistics and Quality, 2020). WORLD DRUG REPORT 2021 REPORT DRUG WORLD

not cover the homeless or institutionalized populations, use of opiates (codeine, heroin and morphine) and tra- who tend to have higher rates of opioid use in the United madol, was reported to be a common pattern. Moreover, States. although tramadol was the most commonly misused opioid in 2013, its pattern of misuse changed in sub- Similar patterns of switch or replacement between opi- sequent years. When tramadol was put under national oids have also been reported in other countries. In a study control in 2014, the use of opiates became more common of a cohort of people in treatment for substance use dis- among opioid users in drug treatment. 147 orders in the United Arab Emirates between 2013 and 2018, polydrug use, including sequential or concurrent Similar overlaps and switches between opioids have been observed in Europe. In Sweden, the opioid market was Fig. 39 Trends in the use of opioids among people dominated by heroin until 2014, with a relatively limited in drug treatment, United Arab Emirates, share of the market for other opioids, such as diverted 2013–2018 fentanyl patches that appeared in the drug market in 148 1,200 2006. In 2014, fentanyl analogues were introduced onto the illegal drug market in Sweden through online sales 1,000 of fentanyl analogues, mainly in the form of nasal sprays 800 but also as tablets, powder and capsules, and have dom- inated the market ever since.149 In Estonia and Finland, it 600 is also well documented that two synthetic opioids, fen-

400 tanyl (in the case of Estonia) and buprenorphine (in the case of Finland), have completely replaced heroin and 200 established themselves on the opioid market.150 Number of samples analysed 0 147 Abuelgasim Elrasheed A. Alhassan and others, “A 6-year review of Opiates Tramadol drug trends in the United Arab Emirates from the perspective of the 2013 2014 2015 2016 2017 2018 National Rehabilitation Centre (NRC), Abu Dhabi”, Current Topics in Toxicology, vol. 16 (2020). 148 Bryce Pardo and others, The Future of Fentanyl and other Synthetic Source: Abuelgasim Elrasheed A. Alhassan and others, “A 6-year review Opioids (Santa Monica, California, RAND Corporation, 2019). of drug trends in the United Arab Emirates from the perspective of the 149 Swedish Police Authority, National Operations Department, Current Topics in National Rehabilitation Centre (NRC), Abu Dhabi”, “Swedish national threat assessment on fentanyl analogues and Toxicology , vol. 16 (2020). other synthetic opioids” (October 2018). 60 Note: Opiates include codeine, heroin and morphine. 150 See also, UNODC, World Drug Report 2020, booklet 4, Cross-Cutting Multiple use of opioids as self-medication In Malaysia, the pattern of injecting buprenorphine among regular opioid users emerged shortly after its introduction in 2002, during the 3 rapid expansion of outpatient opioid agonist treatment The second pattern of multiple use of opioids has been for heroin users, which at that time was provided primar- observed in the context of the concomitant use of opi- ily by general practitioners.154, 155 One survey undertaken oids with non-prescribed opioid agonists and antagonists among 276 opioid users in 2006 showed that more than (methadone, buprenorphine or a buprenorphine and 90 per cent of respondents had a prior history of using combination) available for the treatment of heroin, and about 60 per cent were injecting, on a daily 151 opioid use disorders. The diversion of methadone and basis, the buprenorphine that they had received for the buprenorphine used in the treatment of opioid use disor- treatment of opioid use disorders using a prescription ders and the availability and use of illicit buprenorphine from a private general practitioner.156 Buprenorphine was or morphine have been reported in different regions. withdrawn from the Malaysian pharmaceutical market in One review showed that between 18 and 28 per cent 2006 and replaced with a buprenorphine and naloxone of patients enrolled in outpatient opioid agonist pro- combination157 in 2007.158 grammes (methadone or buprenorphine) across different geographical regions with widely varying treatment Studies that have looked at the misuse of opioid agonists structures had sold, given away or removed their medi- such as buprenorphine or methadone among regular cation while under supervision, or shared it with others opioid users, along with sequential or consecutive use of who had been prescribed medication.152 other drugs such as benzodiazepines, have suggested that these opioids, even if not prescribed in treatment set- In a study among clients in opioid agonist treatment tings, are more commonly used for therapeutic purposes across five sites in Sweden, the majority reported prior than to get high; to self-medicate or to manage the effect use of non-prescribed methadone (88 per cent), buprenor- of the main opioid used, for example, to reduce phine (80 per cent) and a combination of buprenorphine and withdrawal symptoms; to reduce or cease the use of the useopioids of between Overlap OPIOIDS | and naloxone (as and antagonist) (50 heroin; and to self-medicate in order to treat per cent). Most respondents had bought or received or as a result of not being able to access or afford drug the substances from other patients in opioid agonist treatment.159, 160 The same studies have suggested that maintenance programmes, but drug dealers were also a the use of buprenorphine obtained from the illicit market significant source of non-prescribed opioid agonists and rarely represents an attempt to attain and that antagonists. Buprenorphine appeared on the illegal drug its abuse liability in heroin-dependent individuals seems market in Sweden in the 1980s in the form of Temgesic low. Moreover, once opioid users are enrolled in a treat- painkillers and it was launched as a medication (Subu- ment programme, they typically decrease their misuse 153 tex) for treatment of opioid use disorders in the . of buprenorphine obtained on the illicit market.161, 162 It

Issues: Evolving Trends and New Challenges (United Nations publica- 154 Lofwall and Walsh, “A review of buprenorphine diversion and misuse: tion, 2020). the current evidence base and from around the world”. 151 Methadone is an opioid agonist. It is known to produce minimal 155 Balasingam Vicknasingam and others, “ of buprenorphine tolerance and alleviates craving and compulsive use. As a long-act- and buprenorphine/naloxone tablets in Malaysia”, Drug and Alcohol ing agonist, buprenorphine prevents withdrawal and craving and Dependence, vol. 111, Nos. 1 and 2 (September 2010), pp. 44–49. stabilizes opioid receptors. As a high-affinity agonist, buprenorphine 156 Ibid. blocks other opioids from binding, preventing misuse of other opi- 157 To prevent misuse of buprenorphine, as naloxone precipitates acute oids. Naloxone in combination with buprenorphine prevents misuse withdrawal if it is crushed and injected. of buprenorphine because naloxone precipitates acute withdrawal if it is crushed and injected. See, Thomas R. Kosten and Tony P. George, 158 Vicknasingam and others, “Injection of buprenorphine and “The neurobiology of opioid dependence: implications for treatment”, buprenorphine/naloxone tablets in Malaysia”. Science and Practice Perspectives, vol 1, No.1 (July 2002), pp. 13–20). 159 Schuman-Olivier and others, “Self-treatment: illicit buprenor- 152 Michelle R. Lofwall and Sharon L. Walsh, “A review of buprenorphine phine use by opioid-dependent treatment seekers”, Journal of diversion and misuse: the current evidence base and experiences Substance Abuse Treatment, vol. 39, No. 1 (July 2010), pp. 41–50. from around the world”, Journal of Addiction Medicine, vol. 8, No. 5 160 Alexander R. Bazazi and others, “Illicit use of buprenorphine/nalox- (September–October 2014), pp. 315–326. one among injecting and noninjecting opioid users”, Journal of 153 Bjorn Johnson and Torkel Richert, “Non-prescribed use of methadone Addiction Medicine, vol. 5, No. 3 (September 2011), pp. 175–180. and buprenorphine prior to opioid substitution treatment: lifetime 161 Comer and others, “Abuse liability of prescription opioids compared prevalence, motives, and drug sources among people with opioid to heroin in morphine-maintained heroin abusers”. dependence in five Swedish cities”, Journal of , vol. 16, 162 Schuman-Olivier and others, “Self-treatment: illicit buprenorphine No. 31 (May 2019). use by opioid-dependent treatment seekers”. 61 seems that both inadequate and stringently controlled Another situation in which opioid users can inadvertently access to opioid maintenance treatment may be a poten- be exposed to other opioids is through the use of falsified tial risk factor for the continued diversion and misuse of or substandard substances to self-treat drug use disor- opioid agonist therapeutic agents.163 ders. One study in Tehran, Islamic Republic of Iran, that looked at medication purportedly sold to treat opioid Beyond the misuse of opioid agonists, there is a niche for use disorders found that the most common substances the use of NPS opioids among some segments of recent present in the samples collected were , NPS users who may also have used opioids in the past, tramadol, other opioids (morphine, codeine) and acet- or currently use them. The use of NPS opioids among aminophen.170 These falsified medicines are purportedly this group is also seen in the context of self-medication, sold by herbalists in that country to people seeking in particular for coping with everyday life situations and self-treatment for opioid use disorders. physical or emotional issues such as pain, stress, 164 and sometimes and addiction. Supply of opiates versus supply of synthetic opioids Inadvertent exposure to or use of opioids The point of origin of opiates and synthetic opioids differs The third pattern of use of multiple opioids, inadvertent greatly. Opiates found on illicit markets originate primar- exposure to or use of opioids, is common as part of the ily in or close to the few areas where opium is produced,

WORLD DRUG REPORT 2021 REPORT DRUG WORLD current opioid crisis in North America and also in the namely, South-West Asia (notably Afghanistan), South- context of NPS opioids emerging on different markets. East Asia (notably Myanmar) and Latin America (notably It is more of a supply-driven dynamic. In such contexts, Mexico).171 By contrast, the origin of synthetic opioids is fentanyls are used as an of heroin or are used far less limited, although in recent years, depending on to manufacture falsified pharmaceutical opioids, such as the specific substance, manufacture has been concen- falsified oxycodone or hydrocodone and even falsified trated in just a few subregions: East and South-East Asia, benzodiazepines, which are then usually sold to a large South Asia and, to a lesser extent, North America and and unsuspecting population of users of not only opioids Europe.172 While many synthetic opioids found on illicit but also cocaine and other stimulants.165, 166 The inadver- markets are legally manufactured before being diverted tent use of fentanyls in the United States is clear: only 0.1 into illicit channels (mainly within national borders),173 per cent of the population aged 12 and older self-reported some are also illegally manufactured and subsequently the non-medical use of fentanyls in 2019, yet they account trafficked. for the majority of the overdose recorded in the country.167 Fentanyls and NPS opioids have also been sold Other than from a few reports published in some coun- on illegal markets in Western and Central Europe, both tries or regions, which show a rather mixed picture, it is on online platforms and the streets, as, or mixed with, difficult to assess in a systematic way whether opiates and heroin and falsified opioids.168, 169 synthetic opioids are trafficked by the same or different organized crime groups. Data from the United States, for 163 Lofwall and Walsh, “A review of buprenorphine diversion and misuse: example, suggest that many of the groups involved in the current evidence base and experiences from around the world”. trafficking in heroin are now also involved in trafficking 164 Christophe Soussan, Martin Andersson and Anette Kjellgren, “The in synthetic opioids. Mexican organized crime groups are diverse reasons for using novel psychoactive substances: a qualitative study of the users’ own perspectives”, International Journal of Drug involved in the export not only of heroin from Mexico to Policy, vol. 52 (2018), pp. 71–78. the United States, but also of fentanyl and its analogues. 165 Patil Armenian and others, “Fentanyl, fentanyl analogs and novel synthetic opioids: a comprehensive review”, , vol. 134, part A (2018), pp. 121–132. 170 Hamid Reza Khoddami-Vishteh and others, “Component analysis of 166 United States, Department of Justice, Drug Enforcement Administra- the illegal handmade pills and capsules for self-medicating substance tion, 2018 National Drug Threat Assessment (October 2018). dependence in Tehran, Iran”, Addiction and Health, vol. 10, No. 1 167 See also booklet 3, Drug Market Trends: Cannabis and Opioids, of the (January 2018), pp. 17–23. present report. 171 See booklet 3, Drug Market Trends: Cannabis and Opioids, of the 168 EMCDDA, European Drug Report 2017: Trends and Developments present report. (Luxembourg, Publications Office of the European Union, 2017). 172 INCB, Drugs: Estimated World Requirements for 2020 – 169 Jolanta B. Zawilska, “An expanding world of novel psychoactive Statistics for 2018 (E/INCB/2019/2), (New York 2020) and previous substances: opioids”, Frontiers in Psychiatry, vol. 8, art. No. 110 years. 62 (June 2017). 173 Ibid. Those groups include the and the Jalisco For years, fentanyl derivatives originating from illicit man- New Generation Cartel. In a number of cases, fentan- ufacture in the Russian Federation have been trafficked 3 yl-laced heroin, namely, mixtures of heroin with fentanyl for distribution in the Baltic States, in particular Estonia, analogues, originating in Mexico have been found in the although in both 2018 and 2019, no shipments from the United States. Russian Federation were discovered and shortages in the availability of fentanyl resulted in sharp declines in Mexican organized crime groups, in particular the Sinaloa the number of fentanyl-related deaths in Estonia in 2018 Cartel, were also identified as suppliers of Dominican and 2019.176 Most of the fentanyl derivatives originating organized crime groups operating in the United States in China are purchased throughout the European Union that are involved in the sale of heroin and fentanyl in the on online platforms on the clear web and the dark web.177 north-east of the country, most notably in New England. Some of the fentanyl sold by Dominican organized crime groups operating in the United States is also shipped from fentanyl-milling operations in the Dominican Republic. By contrast, Colombian organized crime groups oper- ating in the United States that are involved in cocaine and heroin trafficking do not yet appear to have taken up trafficking in fentanyl and its analogues. Street gangs, prison gangs and outlaw motorcycle gangs have been found to be involved in trafficking a number of drugs, including methamphetamine, cocaine, heroin and, to a lesser extent, prescription and counterfeit pills.174

In Europe, on the other hand, information suggests that Overlap between the useopioids of between Overlap OPIOIDS | the markets for opiates and synthetic opioids are more separated than in the United States. There is one very large and distinct market for heroin and, depending on the country, quite large markets for diverted opioid pharmaceuticals such as buprenorphine, methadone and tramadol, and a small, although potentially highly prob- lematic, market for fentanyl and its analogues.

Heroin is mainly trafficked to Western and Central Europe overland along the Balkan route and partly by sea along the southern route, with the subsequent redistribution of heroin from trafficking hubs, such as the ports of Rot- terdam in the Netherlands and Antwerp in Belgium, to major consumer markets in Western and Central Europe. By contrast, synthetic opioids are increasingly traded online and dispatched to countries in the subregion by post from legal or quasi-legal sources, including in China and India and, to a far lesser extent, in Europe: a few illicit laboratories have been detected in France, Estonia, Latvia and Ukraine in recent years.175

174 United States, Department of Justice, Drug Enforcement Administra- tion, 2019 National Drug Threat Assessment (December 2019). 175 EMCDDA and European Union Agency for Law Enforcement Cooperation (Europol), EU Drug Markets Report 2019 (Luxembourg, 176 UNODC, responses to the annual report questionnaire. Publications Office of the European Union, 2019). 177 EMCDDA and Europol, EU Drug Markets Report 2019. 63 WORLD DRUG REPORT 2021 REPORT DRUG WORLD

64 OPIOIDS 3

Demand for opioids Common characteristics of the opioid crises Among people who use drugs, the non-medical use of in Africa and North America opioids has always been associated with more negative health consequences than the use of any other drug type. > The ease and low cost of manufacture and easy accessibility The non-medical use of opioids is attributed to 12.9 mil- of tramadol and fentanyls make the illicit markets for those lion DALYs (healthy years of life lost due to disability and substances substantially more profitable for traffickers than premature ), or 70 per cent of the total 18 million the markets for other opioids, such as heroin. DALYs attributed to drug use disorders. The use of opioids also contributes to the majority of deaths attributed to > The large-scale manufacture of tramadol and fentanyls for drug use disorders and contributes significantly to the the illicit market emerged in the context of an absence of opioids Demand for OPIOIDS | number of deaths attributed to cancer, cirrhosis and international regulations on tramadol and many fentanyl other chronic liver diseases resulting from hepatitis C, analogues and their precursors. 178 as well as to those attributed to HIV and AIDS. Heroin > The fact that the substances available on pharmaceutical remains the opioid of major concern for the great major- markets can be misused interchangeably with those on the ity of countries, but in some countries and subregions, illicit market makes it increasingly difficult to prevent their the non-medical use of pharmaceutical opioids has trig- misuse, especially when their use is seen in the context of gered new health threats in the last few years and has medical use and is thus perceived to carry less stigma or is come to be known as an opioid crisis. subject to less severe legal sanctions than other controlled The non-medical use of pharmaceutical opioids is not drugs. a new phenomenon, however. It has been observed for decades as part of the polydrug use pattern seen among high-risk or regular opioid users. What characterizes In North America, the introduction of fentanyl and its the most recent in North America is analogues (fentanyls) into the drug market has resulted in the alarming rate of deaths that are an unprecedented increase in opioid overdoses attributed attributed mainly to synthetic opioids (fentanyls), while to synthetic opioids. Earlier, the opioid epidemic in North in West, Central and North Africa, the non-medical use America was characterized by cyclical waves of heroin use of pharmaceutical opioids such as tramadol is of con- and non-medical use of pharmaceutical opioids although cern. The health impacts of the surge in the markets in recent years, the non-medical use of opioids and use for fentanyls and tramadol appear to be different: the of heroin has stabilized (in the United States). Fentanyls emergence of fentanyls has not increased the number of found on the illicit market are mainly used as adulterants people who use opioids, but it has driven up the number in heroin or other drugs or sold as falsified pharmaceu- of overdose cases mainly among existing opioid users. tical drugs, with the result that users are often unaware Tramadol, on the other hand, seems to have driven up that they are consuming them. As a result, due to the use among a wider segment of the population and has unpredictability of the potency of the different fentan- led to an increasing number of people in treatment rather yls, many users end up with non-fatal or fatal overdose. than driving up the number of deaths, although reliable information on overdoses is not available for Africa. In West, Central and North Africa and the Middle East, tramadol, a pharmaceutical opioid not under interna- tional control, has emerged as a major opioid of concern. 178 See also booklet 2, Global Overview of Drug Demand and Drug Supply, The drug, in addition to being diverted from the legal of the present report. market, is mainly trafficked into those subregions in 65 dosages higher than those prescribed for pain man- Fig. 40 Global estimates of the number of people who use opioids agement, resulting in an increasing number of people and prevalence of opioid use, 2010–2019 with tramadol use disorder entering treatment in recent 80 1.4 years.179, 180 While the rapid spread of the non-medical use of tramadol is evident, in general there are serious infor- 70 1.2 mation gaps with respect to its market, and measurable 60 1.0 information on its impact on health (or on drug-related 50 0.8 deaths and overdoses) is limited. 40 0.6 30 Another key difference in the spread of the non-medical 0.4 use of tramadol and fentanyls is that the use of fentan- 20 10 0.2

yls is mainly supply driven. In the case of tramadol, this Number of users (millions) 0 0.0 is less clear. Although in some areas the market for the Annual prevalence (percentage) non-medical use of tramadol may have emerged as a result of easy access in unregulated pharmaceutical mar- 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 kets, there are indications that it may have been mainly Number of users Prevalence of use demand driven, at least until 2017. In addition, the use of use a drug is to a large extent related to the availability Source: UNODC estimates, based on responses to the annual report questionnaire. WORLD DRUG REPORT 2021 REPORT DRUG WORLD of the drug more than to an individual’s preference to Note: Annual prevalence of opioid use in the past year among the population aged 15–64. Number of use or misuse a particular substance.181 users aged 15–64 in the past year. Opioids include opiates and synthetic opioids, including pharmaceutical opioids used for non-medical purposes. Number of opioid users worldwide has nearly doubled since 2010 for South Asia have been revised upward, mainly owing to In 2019, nearly 62 million people were estimated to be the availability of new estimates from India; the increase past-year users of opioids, including people who use in Africa is attributed to more robust estimates from opiates and people who use pharmaceutical opioids Nigeria in 2019. for non-medical purposes; this corresponds to 1.2 per cent of the global population aged 15–64. Among opioid Opioid use in Asia increased in South-West users, about half (31 million) had used opiates (heroin and South Asia but declined in East and and opium) in the past year (0.6 per cent of the popula- South-East Asia tion aged 15–64). Between 2010 and 2019, the estimated number of opioid users worldwide nearly doubled, from Although the prevalence of opioid use in Asia is compa- just over 31 million to just under 62 million estimated rable to the global average, more than half of the global past-year users. Over the same period, the prevalence of estimated number of opioid users reside in the region. opioid use increased by 76 per cent, whereas the global High levels of opioid use are estimated in South-West population increased by 10 per cent. Asia (Afghanistan, Iran (Islamic Republic of) and Paki- stan), where the past-year prevalence is estimated at The main increase in the global number of opioid users 3.2 per cent of the adult population, or 6.8 million esti- in recent years has been driven by a number of new esti- mated past-year users of opioids. In both South-West mates made available for Asia and Africa. The estimates Asia and South Asia, opiates (heroin in the case of Paki- stan and India and opium in the case of Afghanistan and Iran (Islamic Republic of)) are the predominant opioids 179 UNODC, European Union and ECOWAS, West African Epidemiology Network on Drug Use (WENDU) Report: Statistics and Trends on Illicit that are misused. The non-medical use of pharmaceuti- Drug Use and Supply 2014–2017 (2019). cal opioids is, however, at a comparable level to that of 180 See also, UNODC, World Drug Report 2020, booklet 4, Cross- Cutting Issues: Evolving Trends and New Challenges (United Nations opiates in those subregions. In the Islamic Republic of publication, 2020). Iran, the non-medical use of tramadol is also reported; a 181 Mai Taha and others, “Cannabis and tramadol are prevalent among estimated the pooled past-year preva- the first episode drug-induced in the Egyptian population: single center ”, Reports: Medic Cases, Images and Videos, vol. lence among the general population as ranging between 66 10 2, No. 2, art. No. 16 (June 2019). 3.7 and 6.0 per cent among men and 0.1 and 3.3 per cent Fig. 41 Opioid use, by region and subregion, 2010 and 2019 3

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Fig. 42 People who use opioids, by region and subregion, 2019 among women, based on studies conducted between 2006 and 2018.182 80 70 In India, 2.1 per cent of the population aged 10–75, a total 60 of 23 million people, were estimated to be past-year 50 opioid users in 2018. The opioid with the highest preva- 40 lence of use was heroin, with a past-year prevalence of 1.1 per cent among the population aged 10–75, followed

Millions 30 by the non-medical use of pharmaceutical opioids, the 20 prevalence of which reached almost 1 per cent of the 10 general population, and opium, the prevalence of which 0 was almost 0.5 per cent.183 Among the 23 million past- Asia

ASIA year opioid users, 7.7 million were estimated to suffer Africa Global AFRICA Europe EUROPE GLOBAL from opioid use disorders. Oceania OCEANIA South Asia Americas AMERICAS Eastern and Eastern Central Asia Central North Africa South Asia Western and Western North Africa South America North America Central Europe Central Although no recent survey estimates are available from South America North America and Transcaucasia individual countries in East and South-East Asia, based on and South-West Asia and South-West Near and Middle East Near and Middle South-Eastern Europe South-Eastern UNODC estimates, opioid use in the subregion appears East and South-East Asia and South-East East to have declined over the period 2010–2019. In 2019, in East and South-East Asia and South-East East UNODC estimates, based on responses to the annual report questionnaire. East and South-East Asia, nearly 3.3 million people, or 0.2 Western and Central Europe

Notes: Opioids include opiates and synthetic opioids, and Transcaucasia Asia Central including pharmaceutical opioids used for 182 Yasna Rostam-Abadi and others, “Tramadol use and public health non-medical purposes. Data are not shown for subregions where recent estimates (not older than 10 years) were not available from countries and subregional estimates could thereforeEastern and South-Eastern Europe not be computed. For consequences in Iran: a systematic review and meta-analysis”, 2019, the estimated number of people who used opioids in the past year is based on prevalence estimates Addiction, vol. 115, No. 12 (December 2020). from 102 countries, covering 81 per cent of the world’s population. Of those, new data points were 183 Atul Ambekar and others, Magnitude of Substance Use in India (New reported for five countries in 2019. Delhi, Ministry of Social Justice and Empowerment, 2019). 67 Near and Middle East and South-West Asia Fig. 43 Use of opiates, by region and subregion, 2019

Annual prevalence of use Number of users 2.5 45 40 2.0 35 30 1.5

Millions 25 20

Percentage 1.0 15 0.5 10 5 0.0 0 Asia ASIA Asia ASIA Africa Africa Global Global AFRICA AFRICA Europe Europe EUROPE GLOBAL EUROPE GLOBAL West and West West and West Oceania Oceania OCEANIA OCEANIA South Asia South Asia Americas Americas AMERICAS AMERICAS Eastern and Eastern Eastern and Eastern Central Asia Central Central Asia Central North Africa South Asia Western and Western North Africa South Asia Western and Western Central Africa Central Central Africa Central North Africa North Africa South America North America Central Europe Central South America North America Central Europe Central South America South America and Transcaucasia North America North America and Transcaucasia and South-West Asia and South-West and South-West Asia and South-West Near and Middle East Near and Middle Near and Middle East Near and Middle South-Eastern Europe South-Eastern South-Eastern Europe South- DRUG REPORT 2021 REPORT DRUG WORLD East and South-East Asia and South-East East East and South-East Asia and South-East East Westand Central Africa Westand Central Africa East and South-East Asia and South-East East UNODC estimates, based on responses to the annual report questionnaire. Asia and South-East East Western and Central Europe Notes: Opiates include opium and heroin. Data are not shown for subregions where recent estimates (not older than 10 years) were not available from countries and subregional estimates could thereforeWestern and Central Europe not be Central Asia and Transcaucasia Asia Central computed. For 2019, the estimated global prevalence and number of people who used opiates in the past year is based on prevalence estimates from 85 countries, covering and Transcaucasia Asia Central 80 per cent of the world’s population. Of those, new data points were reported for seven countries in 2019. Eastern and South-Eastern Europe Eastern and South-Eastern Europe

per cent of the population, were estimated to have used consumption was considered to be similar to that seen Near and Middle East and South-West Asia opioids in the past year. In China, notwithstanding the in previous wastewater studies in the country.Near and Middle East and South-West Asia limitations of data on registered drug users and in the absence of data on the prevalence of opioid use among With a past-year prevalence of 1 per cent of the adult the general population, the absolute number of heroin population (more than half a million users), opioid use users registered declined by a quarter over the period in Central Asia and Transcaucasia is also high. Although 2010–2019; the number of opioid users declined by 50 heroin has been the predominant opioid used in the sub- per cent as a proportion of the total number of drug users region, in recent years there has been a reported decline registered in the country.184 in the official numbers of registered opioid users and of those in drug treatment. An increasing number of syn- Wastewater analysis undertaken in 2018 and 2019 in 25 thetic drugs, such as , and cities across China showed an average drug consumption alpha-PVP, have also appeared on the market, although it of 56.7 mg per day per 1,000 inhabitants (56.7 ± 56.8 mg remains to be seen whether they have substituted opiates per day per 1,000 inhabitants), with heroin consumption or attracted new users. It seems that, rather than sub- second after methamphetamine.185 The consumption of stituting opiates, the consumption of these stimulants heroin was higher in south-west China (108 ± 147 mg per is often combined with cannabis and opioids, result- day per 1,000 inhabitants), central China (59.2 ± 48.0 ing in polydrug use patterns. Regular opioid users, as mg per day per 1,000 inhabitants) and in north-west reported by Uzbekistan, for example, may substitute China (51.5 ± 50.3 mg per day per 1,000 inhabitants) opiates with pharmaceutical opioids such as tramadol or than in other parts of the country. The level of heroin other pharmaceutical drugs with effects, such as , and tropicamide.186

184 China, National Narcotics Control Commission, Report on Drug In Kazakhstan, 120,500 people (about 1 per cent of the Control in China, different years. 185 Si-Yu Liu and others, “Tracing consumption patterns of stimulants, adult population) were estimated to be injecting drugs in opioids, and in China by wastewater-based epidemiology”, Environmental Science and Pollution Research, vol. 28, No. 13 (April 186 Tomas Zabransky and Viktor Mravcik, eds, The 2019 Regional Report 68 2021). on the Drug Situation in Central Asia (, 2019). 100 3,500,000 Fig.100 44 Trends in registered drug users, China, 2010–20193,500,000 Fig. 45 Opioid use among adolescents (aged 15–17), selected countries in North Africa 3 100 3,500,0003,000,000 10080 3,500,0003,000,000 80 1.5 3,000,0002,500,000 80 3,000,0002,500,000 8060 1.3 2,500,0002,000,000 60 2,500,0002,000,000 60 2,000,0001,500,000 1.0 6040 2,000,000

2,000,0001,500,000 Number of users 40 0.8

1,500,0001,000,000 Number of users 40 1,500,000 4020 1,500,0001,000,000 Number of users

40 Number of users

Number of users 0.5 20 1,000,000500,000 Number of users 20 1,000,000500,000 20 0.3 200 500,0000 0 500,0000

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 0.0 0 0 Annual prevalence (percentage) Proportion of users perdrug (percentage) 0 0 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 0 Proportion of users perdrug (percentage) Proportion of users of synthetic drugs (amphetamines) among all 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Proportion of users perdrug (percentage) 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Heroin Heroin Heroin Proportion of users perdrug (percentage)

Proportion2010 2011 of2012 users2013 of 2014 synthetic2015 drugs2016 2017 (amphetamines)2018 2019 among all 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Proportion of users perdrug (percentage) registered drug users Proportion of users perdrug (percentage) Opium/

Proportion of users of synthetic drugs (amphetamines) among all Tramadol Proportionregistered drug of users users of syntheticother drugs drugs among (amphetamines) all registered amongdrug users all morphine Proportion of users of synthetic drugs (amphetamines) among all registeredProportion drug of users users of other drugs among all registered drug users registered drug users Proportion of users of other drugs among all registered drug users Buprenorphine Proportion of users of otherheroin drugs among among all registered all registered drug drugusers users Proportion of users of heroinother drugs among among all registered all registered drug drugusers users Algeria Egypt Morocco Tunisia opioids Demand for OPIOIDS | Proportion of users of heroin among all registered drug users ProportionTotal number of usersof registered of heroin drug among users all registered drug users (2016) (2016) (2017) (2017) TotalProportion number of usersof registered of heroin drug among users all registered drug users TotalNumber number of registered of registered users drugof heroin users Total number of registered drug users Source: Council of Europe, Pompidou Group, Mediterranean School Number of registered users of heroin Survey Project on Alcohol and other drugs (MedSPAD) reports for Algeria, Source: China,Number National Narcoticsof registered Control users Commission, of heroin Report on Drug Control in China, Egypt, Morocco and Tunisia. different years.Number of registered users of heroin

2016. This estimate has remained more or less unchanged In 2018 in Nigeria, 4.6 million people, or 6.0 per cent over the past 10 years. Among those injecting, although of the male and 3.3 per cent of the female population they were injecting multiple drugs, consecutively or aged 15–64, were estimated to have used opioids (mainly sequentially, the majority reported injecting heroin, fol- tramadol but also codeine and morphine) in the past lowed by concoctions of opium poppy (koknar or khanka, year. In addition, 2.3 per cent of the population (an equal desomorphine and tropicamide).187, 188 proportion of men and women) reported the misuse of codeine-based in Nigeria in 2018.189 Opioid use in Africa In North Africa, the non-medical use of tramadol is also With 1.2 per cent of the population having used opioids a major issue in Egypt, where an estimated 3 per cent of in the past year, opioid use in Africa was comparable to the adult population misused tramadol in 2016, the latest the global average in 2019. While the population aged year for which data are available. Similarly, in 2016, 1.4 per 15–64 in the region grew by 10 per cent over the period cent of secondary school students in Egypt reported the 2010–2019, the estimated number of past-year opioid non-medical use of tramadol in the past year.190 Among users increased fourfold and the prevalence of opioid use other countries in the subregion, for which recent infor- increased threefold. Although heroin use is commonly mation is available from school surveys, the pattern of reported by many countries in the region, the non-med- opioid use differs, with heroin reportedly used by adoles- ical use of tramadol has emerged as a major problem, cents in Algeria and Morocco and buprenorphine misused especially in West and Central Africa and in North Africa. in Tunisia.191

187 Ganina L. Yu and others, Report on the Population Size Estimation of 189 UNODC and Nigeria, Drug use in Nigeria 2018 (Vienna, 2019). People Who Inject Drugs (PWID) in the Republic of Kazakhstan (Almaty, 190 Menan Rabie and others, “Prevalence updates of substance use Ministry of Health and Social Development of Kazakhstan, Republi- among Egyptian adolescents”, Middle East Current Psychiatry, vol. 27, can Centre for AIDS Prevention and Control, 2016). No. 4 (February 2020). 188 Oleg Yussopov and others, National Report on Drug Situation in the 191 Council of Europe, Pompidou Group, Mediterranean School Survey Republic of Kazakhstan 2018 (Central Asia Drug Action Programme, Project on Alcohol and other drugs (MedSPAD) reports for Algeria, 2018). Egypt, Morocco and Tunisia. 69 Among people in treatment, heroin remained one of the Fig. 46 Non-medical use of pharmaceutical opioids in main problem drugs across most sites reporting treat- the past 12 months, Australia, 2016 and 2019 ment data for 2019 in South Africa.192 Across different reporting sites, between 2 and 40 per cent of people Other pharmaceutical attending specialized drug treatment services reported opioids, 15% heroin as their primary or secondary substance of con- Codeine, 88% cern. The use of heroin also includes the local variants of Oxycodone, heroin known as nyaope and .193 In addition, about 17% 3 per cent of people accessing drug treatment services in South Africa reported the non-medical use of codeine.194 Tramadol, 2016 10% Opioid use declining in Australia Fentanyl, 1% Morphine, 4% The past-year prevalence of opioid use in the subregion of Australia and New Zealand (3.3 per cent) was higher than the global average in 2019, although it only reflects the situation in Australia because recent estimates of opioid Other pharmaceutical use are available only for that country. The non-medical opioids, 35%

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Codeine, 61% use of pharmaceutical opioids and the frequency thereof have decreased since 2016 in Australia. In 2019, 2.7 per cent of the population aged 14 and older misused pharma- ceutical opioids in Australia, a decline from 3.6 per cent in 2016; among those who had misused the substances 2019 in the past 12 months, the proportion of people misusing them at least weekly declined from 29 per cent in 2016 Oxycodone, to 19.5 per cent in 2019, although the proportion of those 30% misusing them just once or twice a year increased from 28 per cent in 2016 to 43 per cent in 2019.195 Morphine, 8% Tramadol, 14% Fentanyl, 3% In February 2018, containing codeine were

reclassified as schedule 4 drugs in Australia, meaning Source: Australian Institute of Health and Welfare, National Drug Strategy that they could no longer be purchased from a pharmacy Household Survey 2019, Drug Statistics Series, No. 32 (Canberra, 2020). or chemist without a prescription. The reduced ease of access to these substances resulting from the schedul- ing change may account for some of the reductions in increased diversification of the other substances misused the non-medical use of painkillers and opioids. In 2019, in comparison with 2016.196 although the majority of people misusing pharmaceu- tical opioids continued to misuse codeine, there was Opioid use in South America

The prevalence of opioid use in South America was esti- mated at 0.2 per cent of the adult population (600,000 192 Siphokazi Dada and others, “Monitoring alcohol, tobacco and other drug use trends in South Africa: July–December 2019 – Phase 47”, people) in 2019; recent estimates from Central America Research Brief (Cape Town, South Africa, South African Community and the Caribbean were not available to enable the pro- Epidemiology Network on Drug Use, 2020). duction of estimates of the extent of opioid use in those 193 These are street names for heroin that is often mixed with other regulated and unregulated substances. In South Africa, it is usually subregions. The only recent surveys were conducted in sprinkled on cannabis and/or tobacco and the mixture is rolled into a Chile (2018), which reported a prevalence of non-medical cigarette, or “joint”, and smoked. use of pharmaceutical opioids of 1.1 per cent and negligi- 194 Dada and others, “Monitoring alcohol, tobacco and other drug use trends in South Africa: July–December 2019 – Phase 47”. ble use of opiates (heroin or opium), in Uruguay (2018), 195 Australian Institute of Health and Welfare, National Drug Strategy Household Survey 2019, Drug Statistics Series, No. 32 (Canberra, 70 2020). 196 Ibid. which reported that 4.9 per cent of the adult population In 2019, of over 70,000 overdose deaths reported in had misused pharmaceutical opioids in the past year,197, the United States, nearly 50,000 were opioid overdose 3 198 and in Colombia (2019), which reported a prevalence deaths. Between 2010 and 2019, the number of overdose of 0.3 per cent of non-medical use of opioids.199 deaths attributed to opioids more than doubled, from 21,000 to nearly 50,000. Opioid use in North America appears stable Although the number of overdose deaths attributed to but number of overdose deaths continues to the misuse of pharmaceutical opioids and the use of increase heroin has stabilized in recent years, this gain is offset In North America, although the non-medical use of phar- maceutical opioids is a major issue, it appears to be stable Fig. 48 Trends in overdose deaths attributed to pharmaceutical and the opioid crisis is driven mainly by an increase in opioids and heroin, United States, 2010–2019 the number of opioid overdoses attributed to fentanyl and its analogues. Pharmaceutical opioids Thus, one of the main adverse health outcomes of the Deaths involving pharmaceutical opioids and other opioid crisis in the United States is the unprecedented synthetic opioids (fentanyls)

number of fatal overdose cases attributed to opioids. Deaths involving pharmaceutical opioids without other opioids Demand for OPIOIDS | synthetic opioids 18,000 Fig. 47 Trends in opioid overdose deaths, United 16,000 States, 2010–2019

14,000 4,055 5,444 50,00050,000 12,000 5,417

45,00045,000 10,000 5,876

40,00040,000 Number 8,000 35,00035,000 6,000 30,00030,000 4,000 25,00025,000 Number Number 2,000 20,00020,000 0 15,00015,000

10,00010,000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 5,0005,000 0 0 Heroin Deaths involving heroin and synthetic opioids (fentanyls) 2010 2010 2011 2011 2012 2012 2013 2013 2014 2014 2015 2015 2016 2016 2017 2017 2018 2018 2019 2019 Deaths involving heroin without other synthetic opioids AnyAny opioid opioid 18,000 HeroinHeroin 16,000 PharmaceuticalPharmaceutical opioids opioids 14,000 OtherOther synthetic synthetic opioids opioids (fentanyls (fentanyls and and tramadol) tramadol) 12,000 5,781

10,000 8,091

Source: United States, Centers for Disease Control and Prevention, 9,068 Number National Center for Health Statistics, Wide-ranging Online Data for 8,000 8,746 Epidemiologic Research (CDC WONDER), “Multiple cause of death 6,000 1999–2019”. 4,000 Note: The category “Any opioid” includes all categories of opioid overdose deaths. 2,000 0 197 Uruguay, Uruguay, VIII Encuesta Nacional sobre Consumo de Drogas en Estudiantes de Enseñanza Media: Informe de Investigación (Montevideo, Junta Nacional de Drogas, Observatorio Uruguayo de Drogas, 2020). 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 198 Response submitted by Chile to the annual report questionnaire for 2019. Source: United States, Centers for Disease Control and Prevention, National Center 199 Colombia, Encuesta Nacional de Consumo de Sustancias Psicoactivas, for Health Statistics, Wide-ranging Online Data for Epidemiologic Research (CDC Resultados 2019 (Ministerio de Justicia y del Derecho, August 2020. WONDER), “Multiple cause of death 1999–2019”. 71 by the continuing increase in the number of deaths Fig. 49 Substances submitted to and analysed by forensic laborato- attributed to synthetic opioids (mainly fentanyls). It ries, by type of drug identified, United States, 2009–2019 is important to keep in mind that most fatal overdose 120,000 200,000 cases involve more than one type of drug. Even in the 180,000 case of deaths attributed to opioids, the mixing of dif- 100,000 160,000 ferent opioids along with other drugs is common. A large proportion of overdose deaths attributed to heroin (62 80,000 140,000 per cent of the total 14,000 deaths attributed to heroin) 120,000 and pharmaceutical opioids (42 per cent of the total 60,000 100,000 80,000 14,000 deaths attributed to pharmaceutical opioids) 40,000 also involved synthetic opioids (fentanyls). Fentanyls 60,000 also contribute significantly to the increased number 20,000 40,000 Number of heroin samples of overdose deaths attributed to the use of cocaine and 20,000 other psychostimulants such as methamphetamine.200, 201 0 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Among the reasons for the large number of overdose Number of pharmaceutical opioid samples deaths attributed to fentanyls is that their lethal doses Oxycodone Hydrocodone are often small in relation to those of other opioids: Tramadol Fentanyl WORLD DRUG REPORT 2021 REPORT DRUG WORLD fentanyl, for example, is approximately 100 times more Heroin

potent than morphine, and may be as much Source: United States, Department of Justice, Drug Enforcement Administration, Diversion as 10,000 times more potent than morphine for an aver- Control Division, National Forensic Laboratory Information System reports for different age user. A lethal dose of carfentanil for a human can be years. as low as 20 micrograms.202, 203

The spread of fentanyls in the United States continues to increase in the proportion of samples analysed that were be visible in the analysis of drug samples from seizures, identified as tramadol in 44 states, mostly in the south which shows the gradual diversification of synthetic opi- and north-east of the United States, although tramadol is oids on the market, with a considerable increase since often mixed with other substances. In 2019, of the 8,196 2014 in the number of samples identified as fentanyl. samples that were identified as tramadol, 44 per cent Furthermore, while fentanyl has been the predominant (3,961 samples) contained at least one other drug, the substance seized over the years, its analogues have rap- majority (85 per cent) being fentanyl, while more than idly proliferated in the United States. As a percentage of half (57 per cent) contained heroin, 10 per cent contained all pharmaceutical opioid samples seized and identified in and 7 per cent contained cocaine.205 2019, among notable fentanyl analogues, acetylfentanyl accounted for 6 per cent of identified samples, followed In contrast to the increase in the number of opioid over- by carfentanil (1.6 per cent), valeryl fentanyl (1.0 per cent) dose deaths, the misuse of pharmaceutical opioids and and fluoroisobutyrylfentanyl (0.2 per cent).204 use of heroin in the United States appears to be stabi- lizing, especially since 2017. In 2019, 3.7 per cent of the Tramadol has also been increasingly identified in sei- population (10.2 million people) aged 12 and older in the zure samples: over the period 2010–2019, there was an United States had misused opioids in the past year, 3.6 per cent of the population aged 12 and older (97 per cent 200 Calculated from the overdose deaths reported by the Centers for Dis- of all opioid users) had misused pharmaceutical opioids ease Control and Prevention, National Center for Health Statistics, and 0.3 per cent had used heroin. in the Wide-ranging Online Data for Epidemiologic Research (CDC WONDER), “Multiple cause of death 1999–2019”. However, as in any other country, estimates of heroin 201 See also, “Cocaine use” in booklet 4 of the present report. users based on household surveys are considered as 202 EMCDDA, “Fentanyl drug profile”. 203 United States, Department of Justice, Drug Enforcement Administra- underestimates as they are based on self-reporting and tion, 2019 National Drug Threat Assessment, December 2019. 204 United States, Department of Justice, Drug Enforcement Adminis- 205 United States, Department of Justice, Drug Enforcement Adminis- tration, Diversion Control Division, “National Forensic Laboratory tration, Diversion Control Division, “National Forensic Laboratory Information System: drug 2019 annual report” (Springfield, Virginia, Information System: drug special report – tramadol reported in 72 2020). NFLIS, 2010–2019” (Springfield, Virginia, 2020). Fig. 50 Trends in past-year use of heroin and Fig. 51 Trends in the use of heroin in the United non-medical use of pharmaceutical opioids, as States, based on different studies, 2006–2016 3 reported in household surveys, United States, 2.5 2010–2019 14 2 2.0 12 1.6 1.5 10 8 1.2 1.0

6 Number (millions) 0.8 0.5 4

of users (millions) 0.4 2 0.0

0 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pharmaceutical opioids: number Heroin: number of users(millions) Chronic heroin users (RAND Corporation) 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Past-year heroin users (National Survey)

Pharmaceutical opioids Heroin Past-month heroin users (National Survey) opioids Demand for OPIOIDS |

Source: United States, Substance Abuse and Mental Health Services Sources: Gregory Midgette and others, What America’s Users Spend on Administration, Results from the 2019 National Survey on Drug Use and Illegal Drugs, 2006-2016 (Santa Monica, California, RAND Corporation, Health (NSDUH): Detailed Tables (Rockville, Maryland, Center for 2019); and United States, Substance Abuse and Mental Health Services Behavioral Health Statistics and Quality, 2020). Administration, Results from the 2019 National Survey on Drug Use and Health (NSDUH): Detailed Tables (Rockville, Maryland, Center for Behavioral Health Statistics and Quality, 2020). do not cover the homeless or the institutionalized popu- lations, which tend to have higher rates of opioid use in Fig. 52 Non-medical use of opioids by sociodemographic the United States. For example, in 2016, based on another characteristics, United States, 2019 study, 2.3 million people were estimated to be chronic 7 heroin users in the United States, while the National Survey on Drug Use and Health conducted the same 6 year estimated the number of past-year heroin users to 5 be about 950,000 and the number of past-month heroin users to be just under half a million.206 Although 2.3 times 4 higher, the estimates of chronic heroin users in the 2016 3 study show a similar trend over time to the estimates of past-year use of heroin based on the household survey. 2 1 The extent of the non-medical use of opioids varies con- Annual prevalence (percentage) Male Asian siderably across sociodemographic characteristics in the White Female Full time United States. For example, more men than women use Part time opioids for non-medical purposes, as do American Indian/ Unemployed College graduate Alaska Natives when compared with other ethnic groups. African American Hispanic Latinoor Less thanLess high school

People who are unemployed also report a higher rate of High-school graduate misuse than people who are employed; also, the rate of opioid use among those who did not attend or complete a college degree was higher than among those who were Some College/Associate's degree American Indian or Alaska Native college graduates. Native Hawaiian Pacific or Islander Sex Ethnicity Education Employment

206 Gregory Midgette and others, What America’s Users Spend on Illegal Source: United States, Substance Abuse and Mental Health Services Administration, Drugs, 2006–2016 (Santa Monica, California, RAND Corporation, Results from the 2019 National Survey on Drug Use and Health: Detailed Tables (Rockville, 2019). Maryland, Center for Behavioral Health Statistics and Quality, 2020). 73 Fig. 53 Opioid overdose deaths in Canada, were among men; more than a quarter of all the victims by age group, 2019 were aged 30–39. The majority of the opioid overdose deaths in 2019 were attributed to fentanyl and/or fen- Age 60 and over, 9% Age 19 and under, 2% tanyl analogues.

Age 20–29, The geographical spread of opioid overdose deaths is 19% uneven in Canada. Most opioid overdose deaths are seen in the western parts of the country: British Columbia Age 50–59, (19.9 opioid overdose deaths per 100,000 population); 22% Alberta (14.6 opioid overdose deaths per 100,000 pop- ulation); and Ontario (10.4 opioid overdose deaths per 100,00 population). In the north, Yukon saw 10.2 opioid 211 Age 30–39, overdose deaths per 100,000 population in 2019. 27% Age 40–49, Opioid use in the past year in Mexico was estimated 21% at 0.1 per cent of the adult population in 2016.212 More recently, wastewater analysis of samples collected Source: Canada, Special Advisory Committee on the Epidemic of Opioid between November 2017 and February 2018 in 15 cities Overdoses, Apparent Opioid and Deaths: Surveillance of WORLD DRUG REPORT 2021 REPORT DRUG WORLD across Mexico indicated the emergence of fentanyl use, Opioid and Stimulant-related Harms in Canada, (, Public Health 213 Agency, 2021). at least in the northern parts of the country. This anal- ysis showed heroin metabolites in six sites and none, that is below-detection levels, in seven others; fentanyl In Canada, the opioid crisis is also driven by the use of metabolites above the detection and quantifiable levels pharmaceutical opioids, both diverted from licit channels were found only in two cities, Monterrey and San Luis Río and originating in the illicit market, and an increasing Colorado, which are respectively in the north-east and number of opioid overdose deaths have been attributed north-west of the country. The levels of heroin metabo- 207, 208 to fentanyls since 2016. In 2017, an estimated 12 lites in Monterrey were the highest, at 15.8 mg per day per per cent of the population aged 15 and older in Canada 1,000 population. Low levels of fentanyl metabolites were (3.5 million people) had used pharmaceutical opioids in found in Monterrey (1.1 mg per day per 1,000 population) the past year, of whom about 2 per cent reported the and in San Luis Río Colorado, which borders California, 209 non-medical use of pharmaceutical opioids. United States (0.99 mg per day per 1,000 population). Such levels suggest that, although fentanyl consump- Following an almost 50 per cent increase between 2016 tion does exist in Mexico, it remains low compared with and 2018, from 3,023 deaths (age-adjusted rate of 8.4 that in the neighbouring country of the United States. In deaths per 100,000 population) in 2016 to 4,383 deaths Eastern Kentucky in the United States, for example, the (age-adjusted rate of 11.8 deaths per 100,000 population) level of fentanyl metabolites found in wastewater anal- in 2018, the reported number of opioid overdose deaths ysis in 2018 was 169 mg per day per 1,000 population.214 in Canada declined in 2019 (3,811 deaths, or age-adjusted rate of 10.1 per 100,000 population). However, by Sep- tember 2020, the rate of overdose deaths rebounded, Opioid use in Europe has remained to 16.0 deaths per 100,000 population (4,395 deaths). 210 generally stable since 2016 The majority (72 per cent) of the deaths reported in 2019 The past-year prevalence of opioid use in Europe in 2019 is estimated at 0.7 per cent of the population aged 15–64, 207 Opioid overdose data for Canada are available from 2016. or 3.6 million people. Heroin remains the most commonly 208 Lisa Belzak and Jessica Halverson, “The opioid crisis in Canada: a used opioid in the region. national perspective,” Health Promotion and Chronic Disease Preven- tion in Canada, vol. 38, No. 6 (June 2018). 209 Health Canada, “Canadian Tobacco, Alcohol and Drugs Survey 211 Ibid. (CTADS): summary of results for 2017”, 4 January 2019. 212 Response submitted by Mexico to the annual report questionnaire. 210 Canada, Special Advisory Committee on the Epidemic of Opioid 213 Copytzy Cruz-Cruz and others, “Opioids, stimulants, and Overdoses, Apparent Opioid and Stimulant Toxicity Deaths: Surveillance drugs in fifteen Mexican cities: a wastewater-based epidemiological of Opioid and Stimulant-related Harms in Canada, (Ottawa, Public study”, International Journal of Drug Policy, vol. 88 (2021). 74 Health Agency, 2021). 214 Ibid. Fig. 54 First-time entrants in drug treatment, Russian Federation, Fig. 55 Trends in registered drug users, Russian 2006–2019 Federation, 2010–2019 3 700,000 22.0 20.0 600,000 18.0 500,000 16.0 400,000 14.0

12.0 Number 300,000 10.0 200,000 18.3 8.0 16.7 16.1 15.2 14.5 100,000 6.0 12.2 10.5 0 4.0 7.7 7.2 6.1

2.0 4.2 3.6 2.8 2.7 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 0.0 Total drug users Opioid users 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Number of persons per population persons of 100,000 Number Source: UNODC, responses to the annual report questionnaire for

Opioids different years. opioids Demand for OPIOIDS | Cocaine Psychostimulants Other drugs and combinations Fig. 56 Opioid use in Western and Central Europe, Source: Russian Federation, Ministry of Health. 2010–2019 0.7

With an estimated 1.7 million past-year opioid users in 0.6 Eastern and South-Eastern Europe, the prevalence of 0.5 opiate use remains high (0.8 per cent), despite a decrease 0.4 in the previous years in the overall use of opioids in the subregion, driven primarily by a decrease in the estimated 0.3 number of opioid users in the Russian Federation, based 0.2 on those registered. On the basis of law enforcement data, it is considered that the drug market in the Russian 0.1

Federation has diversified in the last few years, with an Annual prevalence (percentage) 0 increasing number of synthetic drugs, such as the cathi- nones alpha-PVP and mephedrone, and amphetamine, 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 having rapidly gained a share of the market; however, it Source: UNODC estimates, based on responses to the annual report remains to be seen whether they have substituted opiates questionnaire. or have attracted new users. Nevertheless, notwith- standing the limitations of the data on drug treatment provision, there are indications of a substantial decline drug markets.215, 216 However, in recent years, there has over the past 10 years or more in the rate of people enter- also been an increase in the injecting of stimulant NPS ing treatment for the first time for any drug or for opioid (mixed in different proportions) such as mephedrone, use disorders in the Russian Federation, as well as in MPVP, 5-APV, and other in the the number of drug users and opioid users registered country.217 in the country.

In Ukraine, the only available estimates of opioid use are indirect: in 2018, 350,000 people (1.1 per cent of the adult 215 UNAIDS, AIDS Data 2020 (Geneva, 2020). 216 UNODC, Regional Programme Office for Eastern Europe, The Short population) were estimated to be injecting drugs, mostly History of New Psychoactive Substances in Ukraine (Kyiv, 2020). opiates, including heroin and methadone sold on illicit 217 Ibid. 75 Fig. 57 Trends in high-risk opioid use, selected countries in Western and Central Europe, 2010–2018

7

6

5

4

3

2

Rate per population 1,000 1

0 2010 2011 2012 2013 2015 2017 2010 2011 2012 2013 2014 2015 2016 2017 2018 2010 2011 2012 2013 2014 2015 2016 2017 2018 2014 2015 2017 2010 2011 2012 2013 2014 2015 2016 2017 2018 2010 2011 2012 2013 2014 2015 2016 2017 2018 2010 2011 2012 2013 2014 2015 2017 2018 Austria Cyprus Czechia France Germany Greece Italy

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Source: EMCDDA, “Statistical bulletin 2020”. Note: “High-risk opioid use” is defined by EMCDDA as the recurrent use of opioids or other drugs that causes actual harm (negative consequences, including dependence, but also other health, psychological or social problems) to the person, or places the person at a high probability or risk of suffering from such harm.

In Western and Central Europe (mainly the States mem- and reported in the European Union. They are available bers of the European Union) heroin also remains the on the clear web, the dark web and street drug markets, main opioid used. Between 2010 and 2019, the estimated are used to manufacture falsified medicines and are sold number of people who use opioids and the past-year as legal replacements for opioids under international prevalence of opioid use (essentially heroin use) in West- control. In the European Union, , ern and Central Europe increased by about 65 per cent. carfentanil and acrylfentanyl in particular were associ- However, since 2016, opioid use in the subregion has ated with a number of fentanyl-related deaths reported remained generally stable. in 2018.220 However, attempts to gain a share of the illicit opioid market with those drugs have been detected and Nonetheless, recent estimates in Austria, Germany and suppressed in Sweden and the United Kingdom of Great Italy suggest an increase in the use of heroin. In the Euro- Britain and Northern Ireland, for example.221 Data on pean Union, there are an estimated 1.3 million high-risk opioid overdose deaths over the period 2016–2019 in 218 opioid users (0.4 per cent of the population aged 15–64 Sweden clearly show a sudden reduction in the markets in 2018); they use mainly heroin. Heroin availability in the for fentanyls. European Union appears to be stable; the purity of heroin, which increased between 2008 and 2014, and its price, To date, there is no indication of an established market which declined, have both remained stable since then.219 for fentanyls as an adulterant or as a main substance of use in Europe, other than in Estonia, where an isolated In the European market, fentanyls have begun to be niche market for fentanyl has developed since 2013.222 detected in seizures and overdose deaths. Since 2012, There are, however, indications that other opioids, such more than 30 fentanyl analogues have been detected as methadone, buprenorphine, fentanyl, codeine, mor- phine, tramadol and oxycodone, are being misused in 218 As defined by EMCDDA, “high-risk opioid use” is the recurrent use of opioids or other drugs that causes actual harm (negative conse- 220 EMCDDA, Drug-related Deaths and Mortality in Europe: Update from quences, including dependence, but also other health, psychological the EMCDDA Expert Network, July 2019 (Luxembourg, Publications or social problems) to the person, or places the person at a high Office of the European Union, 2019). probability or risk of suffering from such harm. 221 See, for instance, UNODC, World Drug Report 2020, booklet 4, 219 EMCDDA, European Drug Report 2020: Trends and Developments (Lux- Cross-Cutting Issues: Evolving Trends and New Challenges. 76 embourg, Publications Office of the European Union, 2020). 222 Ibid. Fig. 58 Trends in deaths, Sweden, 2016–2019 Fig. 59 Trends in opioid-related deaths, Northern Ireland, 2008–2018 3 120 890 120 880 100 870 100 80 860 850 80 60 840 60 830 Number 40 820 40 810 20 20 800 Number of opioid overdose deaths 0 790 0 2016 2017 2018 2019 Total number of drug overdose deaths 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Heroin All opioids Oxycodone Heroin/Morphine Tramadol Methadone opioids Demand for OPIOIDS | Fentanyl Tramadol Fentanyl analogues Codeine (not from compound formulation) Total drug overdose deaths (not from compound formulation) Oxycodone Source: Sweden, National Board of Forensic Medicine, 2020. Fentanyl Note: Number of poisoning deaths in relation to which the specified substance or substances were detected in blood and assessed as contributing to the death, either alone or in combination with other Source: Northern Ireland Statistics and Research Agency, “Drug-related substances. and drug misuse deaths 2008–2018”, 16 January 2020.

the European Union. For instance, 16 per cent of clients ageing of a large proportion of the opioid-using popu- entering drug treatment for an opioid-related problem in lation, who remain at the greatest risk of drug overdose 2019 reported a synthetic opioid as their main problem death.225 drug.223 By comparison, nearly 10 per cent of all opioid users entering treatment in 2013 did so for disorders The trend in opioid-related deaths in Northern Ireland, related to the use of opioids other than heroin.224 where the rate of drug-related deaths is high (10.0 per 100,000 population) and has more than doubled over Over the past five years, in particular, there has also been the past decade, provides an example of the diversifica- an increase in the number of drug overdose deaths, with tion and spread of the different opioids on the market.226 8 or 9 overdose deaths out of every 10 such deaths in the European Union involving heroin. In 2018, 8,300 over- dose deaths (22.3 deaths per million population aged 15–64), primarily involving opioids, were reported in the European Union, as compared with about 6,000 such deaths reported in 2013. Overdose deaths in Germany and the United Kingdom together accounted for half of overdose deaths in the European Union, where the mean age of those who died from a drug overdose continued to increase, reaching 42 years in 2018. This reflects the

223 EMCDDA, European Drug Report 2020: Trends and Developments. 225 EMCDDA, European Drug Report 2020: Trends and Developments. 224 EMCDDA, European Drug Report 2015: Trends and Developments (Lux- 226 Northern Ireland Statistics and Research Agency, “Drug-related and embourg, Publications Office of the European Union, 2015). drug misuse deaths 2008–2018”, 16 January 2020. 77 WORLD DRUG REPORT 2021 REPORT DRUG WORLD

78 OPIOIDS 3

as well as in Eastern and South-Eastern Europe, Central Access to pharmaceutical opioids Asia and Transcaucasia and South Asia. In other regions for pain management and subregions, the trend was stable, notably in Africa, or even declining, such as in South America, Central Amer- ica and the Caribbean (particularly after 2017) and in East Access to and availability of pharmaceutical and South-East Asia. opioids are highly unequal across regions and subregions Fig. 60 Amounts of opioids under international control (excluding preparations) available for medical consumption, by sub­ Access to and availability of pharmaceutical opioids for region, 2019 pain medication and/or opioid-substitution treatment remain highly unequal across geographical regions and 31,826 subregions and show diverging trends.227, 228 In 2019, on 30,000 a per capita basis, the availability of pharmaceutical opi- 25,000 oids for medical consumption in Africa as a whole and for Melanesia, Polynesia, Micronesia, the Caribbean, South 20,000 Asia, Central America and South America was less than 17,147 15,000 1 per cent of the availability in North America. 12,160 Low- and middle-income countries, which are home to 84 10,000 per cent of the global population, had the lowest avail- 5,000 ability, equivalent to less than 1 per cent of the per capita 3,242 1,401 1,594 344 478 305 247 94 77 76 4 237 174 136 amount of pharmaceutical opioids available for medical 86

DDD per day per1 million inhabitants 0 - consumption in high-income countries in 2019. S Access to pharmaceutical opioids for pain management to pharmaceutical opioids for Access OPIOIDS | Nevertheless, between 2015 and 2019, the amount of opi- Caribbean South Asia East Africa oids controlled under the international drug conventions East Africa North Africa South America available for medical consumption increased by 48 per North America Southern Africa Central America

cent in low- and middle-income countries and declined GLOBAL AVERAGE

by 11 per cent in high-income countries. South-Eastern Europe Westand Central Africa East and South-East Asia and South-East East

These trends were not uniform across subregions, how- New Zealand and Australia Western and Central Europe

ever. The decline in the medical use of such opioids in the and Transcaucasia Asia Central subregions where availability is high over the period 2015–

2019 occurred mainly in North America (even though data Melanesia,Polynesia and Micronesia show an increase between 2017 and 2019) and in Western Near and Middle East/ South-WestAsia and Central Europe, while the increase in medical use in Sources: UNODC calculations based on the following INCB reports: Narcotic Drugs: the subregions where availability is low was observed Estimated World Requirements for 2021 – Statistics for 2019 (E/INCB/2020/2); and Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific mainly in the Near and Middle East/South-West Asia, Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3). 227 INCB, Narcotic Drugs: Estimated World Requirements for 2021 – Note: S-DDD refers to “defined daily doses for statistical purposes”. As defined by INCB, S-DDDs are Statistics for 2019 (E/INCB/2020/2). “technical units of measurement” for the purposes of statistical analysis and are not recommended 228 INCB, Psychotropic Substances: Statistics for 2019 – Assessments of daily prescription doses; actual doses may differ based on treatments required and medical practices. Annual Medical and Scientific Requirements for Substances in Sched- Details of S-DDDs used for these calculations are provided in the methodological annex to the present ules II, III and IV of the Convention on Psychotropic Substance of 1971 report. Regions and subregions are those designated by UNODC in the World Drug Report; they may (E/INCB/2020/3). differ partly from those used by INCB in its publications. 79 Fig. 61 Amount of opioids under international control (excluding preparations) available for medical consumption, by country income level group, 2019

10,000 18,984 20,000 -11% 9,000 18,000 8,000 16,000 7,000 14,000 6,000 12,000

DDD per year 5,000 10,000 4,000 8,000 3,000 6,000 2,000 +48% 4,000

Millions of S - 1,000 2,000 101 0 0 High-income Low- and High-income Low- and DDD per day per1 million inhabitants -

countries middle-income countries middle-income S countries countries Total availability (annual) Per capita availability (per day) WORLD DRUG REPORT 2021 REPORT DRUG WORLD Annual availability, 2015 Annual availability, 2019 Daily availability, 2019

Sources: UNODC calculations based on the World Bank classification of countries by income levels and the following INCB reports: Narcotic Drugs: Estimated World Requirements for 2021 – Statistics for 2019 (E/INCB/2020/2); and Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3). Notes: S-DDD refers to “defined daily doses for statistical purposes”. As defined by INCB, S-DDDs are “technical units of measurement” for the purposes of statistical analysis and are not recommended daily prescription doses; actual doses may differ based on treatments required and medical practices. Details of S-DDDs used for these calculations are provided in the methodological annex to the present report.

The pharmaceutical opioids most available for consump- methadone (notably in the management of cancer tion at the global level in 2019, expressed in S-DDDs, pain)232 and buprenorphine (for acute and chronic pain) were hydrocodone (26 per cent of the total), followed are also used for pain management.233 by methadone (20 per cent), fentanyl (20 per cent), buprenorphine (17 per cent), oxycodone (8 per cent) and The types of pharmaceutical opioids available on the morphine (4 per cent).229 While most pharmaceutical opi- medical market, however, vary significantly between oids (codeine, fentanyl, hydrocodone, , regions and subregions. As shown in Fig. 63, for example, morphine, oxycodone, and pethidine) are in North America in 2019, hydrocodone, buprenorphine used in pain management, methadone230 and buprenor- and methadone were the most widely available pharma- phine are mostly used in the medically assisted treatment ceutical opioids, expressed in daily doses per inhabitant; of opioid use disorders, including in combinations (such the market in Australia and New Zealand in 2019 was as buprenorphine and naloxone).231 In some instances, dominated by methadone and fentanyl; and the market in Western and Central Europe in 2019 was dominated by fentanyl, followed by methadone. Fentanyl also plays an 229 UNODC calculations based on INCB reports: Narcotic Drugs: Estimated World Requirements for 2021 – Statistics for 2019 (E/ important role in the consumption of opioids for medical INCB/2020/2), and previous years; and Psychotropic Substances: purposes in Eastern Europe and South-Eastern Europe, as Statistics for 2019 – Assessments of Annual Medical and Scientific well as in Melanesia, Polynesia and Micronesia, the Carib- Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3), bean and Central America, while the use of methadone and previous years. 230 WHO, Clinical Guidelines for Withdrawal Management and Treatment 232 James D Toombs and Lee A Kral, “Methadone treatment for pain of Drug Dependence in Closed Settings (Geneva, 2009). states”, American Family Physician, vol. 71, No. 7 (April 2005), 231 Danny S. Lee and others, “Rapid induction of buprenorphine/ pp. 1353–1358. naloxone for chronic pain using a microdosing regimen: a case 233 Rohit Aiyer and others, “Treatment of chronic pain with various report”, and Analgesia Practice, vol. 14, No. 2 (January buprenorphine : a systematic review of clinical studies”, 80 2020), pp. 44–47. Anesthesia and Analgesia, vol. 127, No. 2 (August 2018), pp. 529–538. Fig. 62 Trends in the availability of opioids under international control (excluding preparations) for medical consumption, by region and subregion, 2015–2019 3 High-availability subregions Low-availability regions/subregions 40,000 35,994 1,800 1,600 35,000 31,827 1,594 1,400 30,000 1,200

25,000 1,000 800 847 20,000 710 16,884 17,147 600 400 15,000 313 14,670 200 10,000 12,160 0 DDD per day per1 million inhabitants DDD per day per1 million inhabitnats 2015 2016 2017 2018 2019 - - S 5,000 S 283 353 Near and Middle East/South-West Asia 0 Eastern and South-Eastern Europe 2015 2016 2017 2018 2019 East and South-East Asia Central Asia and Transcaucasia North America South America, Central America and Carribean Australia and New Zealand South Asia Western and Central Europe Melanesia, Micronesia, Polynesia Other subregions (low availability) Africa

Sources: UNODC calculations based on the following INCB reports: Narcotic Drugs: Estimated World Requirements for 2021 – Statistics for 2019 (E/ INCB/2020/2), and previous years; and Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3), and previous years. Notes: S-DDDs refers to “defined daily doses for statistical purposes”. As defined by INCB, S-DDDs are “technical units of measurement” for the purposes of statistical analysis and are not recommended daily prescription doses; actual doses may differ based on treatments required and medical practices. Details of S-DDDs used for these calculations are provided in the methodological annex to the present report. Regions and subregions are those designated by UNODC in the World Drug Report; they may differ partly from those used by INCB in its publications; extrapolation techniques have been used in case of missing data. “High-availability subregions” include subregions with per capita availability of opioids for medical purposes that is above the global average, i.e., North America, Western and Central Europe, Australia and New Zealand. pain management to pharmaceutical opioids for Access OPIOIDS | “Low-availability regions and subregions” include regions and subregions with per capita availability of opioids for medical purposes that is below the global average, i.e., Africa, Asia, Eastern Europe, South-Eastern Europe, the Caribbean, Central America, South America, Melanesia, Micronesia and Polynesia, i.e., all regions and subregions except North America, Western and Central Europe, and Australia and New Zealand. seems to be relatively widespread in South-West Asia, most codeine is sold in the form of preparations (often as Central Asia and Transcaucasia and East Africa. The avail- cough ), which fall under Schedule III of the Single ability of buprenorphine for medical consumption, on the Convention on Narcotic Drugs of 1961 as amended by other hand, is widespread in South Asia and, to a lesser the 1972 Protocol and are less strictly controlled inter- extent, in West and Central Africa, while morphine is nationally than other pharmaceutical opioids. For this more readily available, in relative terms, in Africa, most reason, the availability of such preparations is less well notably in Southern Africa, West and Central Africa and documented and therefore not included in the above East Africa. analysis by region and subregion, which is based on national data. At the global level, indeed, preparations The data and trends displayed in the figures should, of opiates (dominated by codeine) accounted for a large however, be interpreted with caution as they exclude share (more than 40 per cent) of all opioids available for tramadol, an opioid that is not under international con- medical consumption in 2019.234 trol and is widely used in some regions. In addition, the limited availability of codeine for medical consumption 234 UNODC calculations based on INCB, Narcotic Drugs: Estimated World shown in the data analysed is a result of the fact that Requirements for 2021 – Statistics for 2019 (E/INCB/2020/2). 81 Fig. 63 Distribution of amounts of opioids under international control (excluding preparations) available for medical consumption, by subregion, 2019

100 Hydrocodone 90 Methadone 80 Fentanyl DDDs per day - 70 Buprenorphine 60 Oxycodone Morphine 50 Hydromorphine 40 30 Oxymorphone 20 Heroin 10 Dihydrocodeine 0 Codeine Pethidine per 1 million inhabitants (percemtage)inhabitants per 1 million Opium

Proportiontotal of amountS of Other opioids Caribbean South Asia East Africa North Africa WORLD DRUG REPORT 2021 REPORT DRUG WORLD South America North America Eastern Europe Southern Africa Central America GLOBAL AVERAGE South-Eastern Europe Westand Central Africa East and South-East Asia and South-East East Australia and New Zealand and Australia Western and Central Europe Central Asia and Transcaucasia Asia Central Melanesia,Polynesia and Micronesia Near and Middle East/South-West Asia Americas Europe Oceania Asia Africa World

Sources: UNODC calculations based on the following INCB reports: Narcotic Drugs: Estimated World Requirements for 2021 – Statistics for 2019 (E/ INCB/2020/2); and Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3). Note: S-DDD refers to “defined daily doses for statistical purposes”. As defined by INCB, S-DDDs are “technical units of measurement” for the purposes of statistical analysis and are not recommended daily prescription doses; actual doses may differ based on treatments required and medical practices. Details of S-DDDs used for these calculations are provided in the methodological annex to the present report. Regions and subregions are those designated by UNODC in the World Drug Report; they may differ partly from those used by INCB in its publications.

Availability of methadone and Most of the increase until 2010 was the result of the buprenorphine for medical consumption higher availability in North America of pharmaceutical on the increase at the global level in the opioids, mostly oxycodone, hydromorphone, hydroco- done and oxymorphone. The availability of methadone last decade, despite diverging trends in and buprenorphine, the opioids used in the medically recent years assisted treatment of opioid use disorders, also saw Following a rapid expansion over the period 1998–2010, marked increases, as did the availability of fentanyl (for the amount of pharmaceutical opioids (expressed in medical use). S-DDD) available for medical consumption declined at Following the introduction of stricter rules to reduce diver- the global level over the period 2014–2018 and stabi- sion to markets for non-medical use in North America, lized in 2019.235 the decline in availability since 2014 has been particu- larly marked in the case of oxycodone, hydrocodone and

235 INCB, Narcotic Drugs 2020: Estimated World Requirements for 2021 – hydromorphone. Nonetheless, in 2019, the subregion 82 Statistics for 2019 (E/INCB/2020/2), and previous years. continued to account for the main share of the global Fig. 64 Global amounts of pharmaceutical opioids Fig. 65 Global amounts of methadone and bupren­ under international control available for orphine available for medical consumption, 3 medical consumption, 1998–2019 1998–2019 4,000 12,000 Methadone 3,500 Buprenorphine 10,000

D 3,000 D DDD 8,000 2,500 S- D of

s 2,000

n 6,000 o i l l

i 1,500 Millions of S -

M 4,000 1,000 2,000 500

0 0 1998 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 1 9 8 2 0 2 0 2 0 4 2 0 6 2 0 8 2 0 1 2 0 1 2 0 1 4 2 0 1 6 2 0 1 8

Methadone Source: INCB, Narcotic Drugs 2020: Estimated World Requirements for Synthetic opioids () 2021 – Statistics for 2019 (E/INCB/2020/2), and previous years. Buprenorphine Notes: S-DDD refers to “defined daily doses for statistical purposes”. As defined by Opiates (analgesics) INCB, S-DDDs are “technical units of measurement” for the purposes of statistical All opiates analysis and are not recommended daily prescription doses; actual doses may differ All opioids based on treatments required and medical practices. Details of S-DDDs used for these calculations are provided in the methodological annex to the present report.

Source: INCB, Narcotic Drugs 2020: Estimated World Requirements for 2021 – Statistics for 2019 (E/INCB/2020/2). Notes: S-DDD refers to “defined daily doses for statistical purposes”. As defined by As with other pharmaceutical opioids, there are large INCB, S-DDDs are “technical units of measurement” for the purposes of statistical differences across countries in the availability of analysis and are not recommended daily prescription doses; actual doses may differ based on treatments required and medical practices. The statistics exclude buprenorphine and methadone for medical purposes, preparations of opioids listed in Schedule III of the Single Convention on Narcotic reflecting a number of factors, including income level,236 Drugs of 1961 as amended by the 1972 Protocol. Details of S-DDDs used for these

calculations are provided in the methodological annex to the present report. The and likely also the use of such substances for pain management to pharmaceutical opioids for Access OPIOIDS | categories “opiates” and “synthetic opioids” include substances used as analgesics, purposes, the number of people with opioid use disorders excluding those used in opioid-substitution treatment. Buprenorphine and methadone are substances used in opioid-substitution treatment and also as and policies regarding opioid-substitution treatment. analgesics. This results in varying coverage of opioid agonist treat- ment for opioid use disorders. amounts of oxycodone (65 per cent), hydromorphone The availability of methadone for medical consumption (83 per cent) and hydrocodone (99 per cent) available for is generally high in North America, Western and Cen- medical consumption. tral Europe and in the most developed parts of Oceania. By contrast, the amounts of buprenorphine and meth- Nonetheless, the individual countries with the highest adone available for medical consumption have clearly availability of methadone for medical consumption on a increased since the late 1980s. Between 2009 and 2019, per capita basis were widely dispersed across continents, the amount of buprenorphine available for medical con- with the highest levels reported in the , fol- sumption rose by 89 per cent, while that of methadone lowed by the United States, Canada, Australia, Mauritius rose by 42 per cent at the global level, although in recent and the Islamic Republic of Iran over the period 2017– years availability of buprenorphine for medical consump- 2019.237 A total of 88 countries reported the availability tion showed a decline, while that of methadone continued increasing. The overall availability for medical consump- 236 UNODC, World Drug Report 2020, booklet 6, Other Drug Policy Issues (United Nations publication, 2020). tion of methadone and that of buprenorphine globally 237 INCB, Narcotic Drugs: Estimated World Requirements for 2021 – remained at similar levels in 2018 and 2019. Statistics for 2019 (E/INCB/2020/2). 83 Fig. 66 Amounts of methadone and buprenorphine available for medical consumption, by region and subregion, 2019 12,536 12,000 Methadone Buprenorphine 10,000

8,000 6,824

6,000

4,000 2,787

2,000 1,316 1,200 DDD per day per1 million inhabitants - 574 S 244 146 4 73 43 116 42 27 22 21 1.4 0 0.5 WORLD DRUG REPORT 2021 REPORT DRUG WORLD Caribbean South Asia East Africa North Africa South America North America Eastern Europe Southern Africa Central America GLOBAL AVERAGE South-Eastern Europe Westand Central Africa East and South-East Asia and South-East East Australia and New Zealand and Australia Western and Central Europe Central Asia and Transcaucasia Asia Central Melanesia,Polynesia and Micronesia Near and Middle East/ South-WestAsia

Sources: UNODC calculations based on the following INCB reports: Narcotic Drugs: Estimated World Requirements for 2021 – Statistics for 2019 (E/ INCB/2020/2); and Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific Requirements for Substances in Schedules II, III and IV of the Convention on Psychotropic Substance of 1971 (E/INCB/2020/3). Notes: S-DDD refers to “defined daily doses for statistical purposes”. As defined by INCB, S-DDDs are “technical units of measurement” for the purposes of statistical analysis and are not recommended daily prescription doses; actual doses may differ based on treatments required and medical practices. Details of S-DDDs used for these calculations are provided in the methodological annex to the present report.

of methadone for medical consumption in 2019, while Exceptions are South Asia, West and Central Africa 67 others, mostly located in Africa, Asia, Oceania, Latin and Eastern Europe: in those subregions, overall, more America and Eastern Europe, reported no such availabil- buprenorphine is available for medical purposes than ity in 2019.238 methadone.

At the global level, as well as in most subregions, metha- In total, 50 countries and territories reported the avail- done is more widely used than buprenorphine. Overall, 74 ability of buprenorphine for medical consumption over countries reported higher levels of availability of meth- the period 2017–2019, while 57 countries, mostly located adone than buprenorphine for medical consumption in in the Americas, Africa and Asia, reported no availability 2019, while in 39 others, buprenorphine was more widely of this opioid for medical consumption.239 available for medical consumption than methadone. 239 INCB, Psychotropic Substances: Statistics for 2019 – Assessments of Annual Medical and Scientific Requirements for Substances in Schedules 238 INCB, Narcotic Drugs: Estimated World Requirements for 2021 – II, III and IV of the Convention on Psychotropic Substance of 1971 84 Statistics for 2019 (E/INCB/2020/2), and previous years. (E/INCB/2020/3). OPIOIDS 3

The country in which the largest amount of opium is Supply of opiates produced continues to be Afghanistan. Accounting for an estimated 83 per cent of global opium production Cultivation of opium poppy and production over the period 2015–2020, opium produced in Afghan- of opium istan supplies markets in neighbouring countries and in Opium production is highly concentrated, with 97 per Europe, the Near and Middle East, South Asia and Africa. cent of estimated production over the period 2015–2019 A small proportion of the opium produced in Afghani- coming from just 3 of the 50 countries worldwide where stan supplies markets in North America (notably Canada) opium production is reported, directly or indirectly. and Oceania. Supply of opiates Supply of OPIOIDS |

Change from GLOBAL CULTIVATION previous year GLOBAL NUMBER OF USERS

 +  

ha s  ser , d u  i io  p o  million , x rs se u e t

a

i p

 o million

Change from GLOBAL PRODUCTION previous year GLOBAL SEIZURES

 -  

    , tons of opium tons tons tons tons , –, morphine pharmaceutical heroin opium tons opioids processed into heroin  – tons Change from previous year of heroin produced ,– ,  tons consumed as opium -  +  +  +  85 Opium produced in countries in South-East Asia, mostly No data for Mexico, the country where most opium is Myanmar (accounting for 7 per cent of global opium produced in the Americas, are yet available for 2020. production) and, to a lesser extent, the Lao People’s However, data available for the period 1 July 2018–30 Democratic Republic (about 1 per cent of global opium June 2019 show a decline of 23 per cent in the area under production), supplies markets in East and South-East opium poppy cultivation compared with the same period Asia and in Oceania. Opium produced in countries in a year earlier, to 21,500 ha, the smallest area since 2014. Latin America, mostly Mexico (6 per cent of global opium At the same time, most of the opium poppy continues to production) and, to a far lesser extent, Colombia and be grown in six states located along or close to the Pacific Guatemala (less than 1 per cent of the global total each), coast, most notably the states of Sinaloa and Chihuahua, accounts for most of the heroin supplied to the United in the north, and the state of Guerrero, in the south.244 States and the relatively limited heroin markets of South America. Data show that, in 2019, the last year for which com- prehensive cultivation data are available, 69 per cent Estimated area under opium poppy cultivation of the global area under opium poppy cultivation was grew in 2020 located in Afghanistan, 14 per cent in Myanmar and 9 per cent in Mexico, suggesting that these three countries The global area under opium poppy cultivation increased accounted for 92 per cent of global illicit cultivation of by 24 per cent in 2020 to about 294,000 ha, primarily opium poppy that year. WORLD DRUG REPORT 2021 REPORT DRUG WORLD owing to increases in Afghanistan, where the area under opium poppy cultivation increased by 37 per cent, to Global opium production stabilized in 2020 224,000 ha, the third highest level ever reported in the country, and more than 80 per cent higher than a decade Global opium production, which has shown a long-term earlier.240 Increases were reported in most parts of the upward trend, remained largely stable in 2020 compared country, with the exception of the eastern region, where with the previous year. Nonetheless, at 7,410 tons, it was cultivation declined by 28 per cent, and two provinces in almost 60 per cent higher than a decade earlier, although northern Afghanistan (Balkh and Jawzjan). In Helmand it remained below the peak reported for 2017 (10,240 province, which accounts for more than 50 per cent of tons). total area under opium poppy cultivation in Afghanistan, The stabilization of opium production in 2020 was the opium poppy cultivation rose by 27 per cent in 2020. result of a decline of 20 per cent in opium production in In a number of other provinces, including Badghis and Myanmar245 and the stabilization of opium production Faryab, bordering , and Ghazni and Zabul, in Afghanistan.246 This occurred despite the increase in close to Pakistan, the areas under opium poppy cultiva- the area under opium poppy cultivation in Afghanistan tion doubled.241 and was the result of a lower yield than in the previous By contrast, the area under opium poppy cultivation con- year. Estimated yields ranged from about 18 kg per ha in tinued to decline in Myanmar and fell by 11 per cent, to western Afghanistan to 41 kg of opium per ha in eastern 29,500 ha in 2020. Since 2013, the area under opium Afghanistan, with about 29 kg per ha in south-western poppy cultivation in Myanmar has shrunk by almost 50 Afghanistan, which accounted for 71 per cent of total per cent.242 Opium poppy cultivation in Myanmar con- opium production in the country in 2020. Opium yields tinues to take place mainly in (bordering in Afghanistan thus continued to exceed those in Mexico China, the Lao People’s Democratic Republic and Thai- (around 21 kg per ha in 2018/19)247 and were double those land), which accounted for 84 per cent of the total area in Myanmar (around 14 kg per ha in 2020).248 under opium poppy cultivation in that country in 2020.243 244 UNODC and México, México: Monitoreo de Plantíos de Amapola 2018–2019 (forthcoming). 245 UNODC, Myanmar Opium Survey 2020: Cultivation, Production, and 240 UNODC and Afghanistan, “Afghanistan opium survey 2020: Implications. cultivation and production – executive summary” (April 2020), and 246 UNODC and Afghanistan, “Afghanistan opium survey 2020: previous years. cultivation and production – executive summary”. 241 Ibid. 247 UNODC and México, México: Monitoreo de Plantíos de Amapola 242 UNODC, Myanmar Opium Survey 2020: Cultivation, Production, and 2018–2019. Implications (January 2021), and previous years. 248 UNODC, Myanmar Opium Survey 2020: Cultivation, Production, and 86 243 Ibid. Implications. Fig. 67 Opium poppy cultivation and production of opium, Fig. 68 Farmgate price of dry opium and price of 1998–2020 high-quality heroin in Afghanistan, January 3 2017–April 2021 10,000 400,000 200 4,000 175 3,500 8,000 300,000 150 3,000 125 2,500 6,000 100 2,000 200,000 75 1,500 4,000 50 1,000 100,000 Opium production (tons) 2,000 25 500 0 0 Opium poppy cultivation (hectares) Price of opium (dollars perkilogram) Jan Jan Jan Jan Jan Price of heroin (dollars per kilogram)

0 0 Sep Sep Sep Sep May May May May

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2017 2018 2019 2020 2021 Area under opium poppy cultivation Opium Heroin opiates Supply of OPIOIDS | Opium production: other countries Source: Afghanistan, Ministry of Interior Affairs, “Afghanistan drug price Opium production: Lao People's Democratic Republic monitoring monthly report” (April 2021), and previous years. Opium production: Mexico Opium production: Myanmar Opium production: Afghanistan Fig. 69 Price of in Afghanistan, January 2019–April 2021 Source: UNODC calculations based on UNODC and Afghanistan opium surveys and on responses to the annual report questionnaire. F

400 200 ‒ Note: Data for 2020 are preliminary.

300 150 Taking opium consumption into account, estimated global opium production in 2020 would have been suf- 200 100 ficient to potentially manufacture 454–694 tons of heroin (expressed in export purities), which was similar to the

100 50 (dollars per litre) level reported in the previous year (474–722 tons).249

Drug prices in Afghanistan suggest the availability of 0 0 Average price of qualities B Jul Jul Price for quality A (dollars per litre) Jan Jan Jan Oct Oct heroin continues unabated Apr Apr Apr 2019 2020 2021 Global opium production remained high in 2020 and there have been no indications of any shortages in the Quality A Qualities B, C, D, E, F supply of the drug to consumer markets in recent years. Source: Afghanistan, Ministry of Interior Affairs, “Afghanistan drug price monitoring monthly report” (April 2021). Heroin prices increased at the beginning of 2020 in Afghanistan and remained quite stable until July 2020 before gradually decreasing to the level reported in during the first few months of 2020, reflected in a short- mid-2019.250 Although it is difficult to attribute the price lived peak in its price,251 could have played a role. In any hike of heroin in early 2020 to any factor in particular, a case, prices of high-quality heroin were slightly higher temporary shortage of acetic anhydride in Afghanistan in 2020 than in 2019, suggesting ongoing demand for heroin during the global COVID-19 pandemic, most nota- 249 UNODC, World Drug Report 2020, booklet 3, Drug Supply (United bly in the vicinity of Afghanistan, although the amount of Nations Publication, 2020). 250 Afghanistan, Ministry of Interior Affairs, “Afghanistan drug price monitoring monthly report” (April 2021). 251 Ibid. 87 heroin seized,252 and probably also the amount trafficked, Fig. 70 Global quantities of opioids seized and global opium seem to have declined in Europe in 2020.253, 254, 255, 256, 257, 258 production, 1998–2020

Trafficking in opiates 10,000 300 9,000 270 Global quantities of opiates seized have increased 8,000 240 steadily over the past two decades despite marked 7,000 210 annual fluctuations in opium production 6,000 180 The quantities of both opium produced and opiates seized 5,000 150 have shown an upward trend over the past two decades, 4,000 120 although the increase has been more pronounced in the 3,000 90 amount of opiates seized, suggesting that law enforce- Seizures of opioids (tons) Opium production (tons) 2,000 60 ment authorities may have become more efficient in 1,000 30 intercepting trafficked opiates worldwide. - 0

At the same time, the quantity of opium produced 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 annually has been fluctuating more than the quantity of opiates seized and even more so than the quantity of Opium production WORLD DRUG REPORT 2021 REPORT DRUG WORLD

Seizures of morphine heroin seized annually. This suggests the existence of Seizures of heroin opiate inventories to offset fluctuations in opium pro- Seizures of opium (in heroin equivalents) duction, whereby opium may be temporarily stocked Seizures of pharmaceutical opioids along the supply chain, thus ensuring a smooth supply Opiate seizures (in heroin equivalents) of heroin to the main consumer markets. Trend, opium production Trend, opiate seizures Global quantities of opium and heroin seized remained stable in 2019 Sources: UNODC and Afghanistan opium surveys; UNODC, responses to the annual report questionnaire; and other government sources. In terms of weight, opium continued to be the most inter- Note: A ratio of 10:1 was used to convert opium into heroin equivalents. cepted opiate in 2019 (726 tons), followed by heroin (96 tons) and morphine (26 tons), although when expressed in heroin equivalents, heroin continued to dominate sei- was still one of the fifth largest ever reported. The decline zures of opiates. Despite an overall decline in the quantity in the quantity of opiates intercepted in 2019 was mostly of opiates seized globally in 2019 (7 per cent less than a due to smaller quantities of morphine being seized (41 year earlier, calculated in terms of heroin equivalents), it per cent less than a year earlier). The quantities of opium and heroin seized, by contrast, remained quite stable (3 252 UNODC, Drugs Monitoring Platform. per cent more opium and 1 per cent more heroin com- 253 EMCDDA and Europol, EU Drug Markets: Impact of COVID-19 (Luxembourg, Publications Office of the European Union, 2020). pared with a year earlier). 254 EMCDDA, “Impact of COVID-19 on patterns of drug use and drug-related harms in Europe”, Trendspotter Briefing (Luxembourg, On the basis of the number of countries reporting sei- Publications Office of the European Union, 2020). zures of opiates, trafficking in heroin continued to be 255 EMCDDA, “Impact of COVID-19 on drug use and drug services in Western Balkans”, Trendspotter Briefing (Luxembourg, Publications more widespread in 2019 (102 countries) in geographical Office of the European Union, 2021). terms than trafficking in opium or morphine (52 and 36 256 EMCDDA, “Impact of COVID-19 on drug markets, drug use, drug- countries, respectively). In parallel, seizures of opium related harms and responses in south European Neighbourhood Policy area”, Trendspotter Briefing (Luxembourg, Publications Office and morphine continued to be concentrated in a few of the European Union, 2020). countries, with just three countries accounting for close 257 Amrei Krings and others, “COVID-19 impact on harm reduction programs (testing and counselling) in low threshold drug services in to 98 per cent of the total global quantities of the two Germany” (Berlin, Robert Koch Institut, 2020). substances seized. By contrast, the three countries where 258 EMCDDA, “Impact of COVID-19 on drug markets, drug use, drug-re- most heroin was seized (Turkey, Islamic Republic of Iran lated harms and responses in east European Neighbourhood Policy countries”, Trendspotter Briefing (Luxembourg, Publications Office of and Pakistan) accounted for 48 per cent of the global 88 the European Union, 2020). total in 2019. Fig. 71 Countries and territories reporting the largest quantities of opiates seized, 2019 Iran (Islamic Iran (Islamic 3 Opium 656 Morphine 18.2 Turkey (21%) Heroin 20 Republic of) (90%) Republic of) (71%) Iran (Islamic Iran (Islamic 656 18.2 IranTurkey (Islamic (21%) 20 RepublicPakistan of) (90%) (4%) 30 RepublicAfghanistan of) (71%) 17.6 17 Republic of) (18%) Iran (Islamic Pakistan (4%) 30 Afghanistan 17.6 17 Afghanistan (3%) 24 Pakistan (25%) 6.3 RepublicPakistan of) (18%) (9%) 8 Afghanistan (3%) 24 Pakistan (25%) 6.3 Pakistan (9%) 8 India (0.6%) 4.5 Mexico (2%) 0.4 United States (9%) 8 India (0.6%) 4.5 Mexico (2%) 0.4 United States (9%) 8 China (0.4%) 2.9 China (0.9%) 0.2 China (6%) 6 China (0.4%) 2.9 China (0.9%) 0.2 China (6%) 6 Myanmar (0.2%) 1.6 United States (0.5%) 0.1 Afghanistan (4%) 4 Myanmar (0.2%) 1.6 United States (0.5%) 0.1 Afghanistan (4%) 4 Thailand (0.2%) 1.5 India (0.5%) 0.1 India (3%) 3 Thailand (0.2%) 1.5 India (0.5%) 0.1 India (3%) 3 Turkey (0.2%) 1.3 Turkey (0.1%) 0.03 Egypt (3%) 3 Turkey (0.2%) 1.3 Turkey (0.1%) 0.03 Egypt (3%) 3

United States (0.2%) 1.1 Oman (0.1%) 0.03 Azerbaijan (2%) 2 opiates Supply of OPIOIDS | United States (0.2%) 1.1 Oman (0.1%) 0.03 Azerbaijan (2%) 2 Tajikistan (0.1%) 0.8 Italy (0.1%) 0.02 Belgium (2%) 2 Tajikistan (0.1%) 0.8 Italy (0.1%) 0.02 Belgium (2%) 2 Viet Nam (0.1%) 0.6 Hong Kong, China 0.01 Sri Lanka (2%) 2 Viet Nam (0.1%) 0.6 Hong Kong, China 0.01 Sri Lanka (2%) 2 Canada (0.1% 0.6 Poland 0.01 Viet Nam (2%) 1 Canada (0.1% 0.6 Poland 0.01 Viet Nam (2%) 1 Others (0.2%) OtherOther countries (18%) Others countries (0.2%) 1.7 Other countriesOther 0.030.03 1717 1.7 (18%)

0 200 400 600 00 1010 2020 0 10 20 Tons Tons Tons Sources: UNODC, responses to the annual report questionnaire; and other government sources. Note: Seizures of morphine in Afghanistan refer to 2018. The percentage distribution for each country refers to 2019, thus Afghanistan is not included.

Fig. 72 Geographical distribution of global quantities of heroin and morphine seized, 2019 Majority of the quantities of opiates seized continues Oceania to be reported in Asia, most notably in South-West Africa 0.2% 3% Asia Americas Most opiate seizures are made in or close to the main 8% Near and Middle opium-producing areas. Thus, Asia, where more than 90 East/South-West Asia per cent of global illicit opium production takes places, 45% accounted for 76 per cent of all the quantities of opi- AsiaAsia ates (opium, morphine and heroin) seized worldwide 62%62% (expressed in heroin equivalents) in 2019. Europe East and South-East Asia Expressed in heroin equivalents, the country reporting 27% 9% the largest quantity of opiates seized in 2019 continued South Asia 5% to be the Islamic Republic of Iran, which accounted for Central Asia and more than half (52 per cent) of the global total, followed Transcaucasia 3% by Turkey (10 per cent), Pakistan (9 per cent), the United Source: UNODC, responses to the annual report questionnaire. States (4 per cent), China (3 per cent) and Afghanistan Note: Total of 121 tons of heroin and morphine seized in 2019. (3 per cent). 89 Decline in quantities of heroin and morphine seized Record quantities of opiates intercepted in Europe in the main opium-producing areas continued in 2019 in 2019 The Near and Middle East/South-West Asia continued Accounting for 27 per cent of the global total in 2019, to report the largest quantities of heroin and morphine the largest quantities of heroin and morphine seized seized at the global level. Those subregions together outside Asia were reported in Europe; these quantities accounted for almost half (45 per cent) of the global tripled from 2016 to 2019 to reach a record high of 32 quantities of heroin and morphine seized in 2019, with tons. This was likely a direct result of the increase in the largest quantities reported by the Islamic Republic trafficking stemming from the record peak in opium pro- of Iran, followed by Pakistan and Afghanistan, account- duction in Afghanistan two years prior to that. Although ing for 99 per cent of all such quantities seized in these the quantities seized were still increasing in 2019, the subregions. Parallel to the decline in opium production in rate of increase slowed, from 116 per cent in 2017 to 22 Afghanistan from a peak in 2017, the quantities of heroin per cent in 2018 and 9 per cent in 2019. and morphine seized in the Near and Middle East/South- West Asia also declined from a peak in 2017 (60 per cent The largest increase in the quantities of heroin and decline between 2017 and 2019). Preliminary data sug- morphine seized in Europe in 2019 was reported in gest, however, that in parallel with the stabilization in South-Eastern Europe, which also accounted for the bulk opium production in Afghanistan in 2020, the downward (66 per cent) of all such amounts seized in Europe in 2019,

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 259, 260 followed by Western and Central Europe (close to 28 trend in the quantities seized came to a halt in 2020. per cent) and Eastern Europe (6.5 per cent). The largest Accounting for 9 per cent of the global total in 2019, the quantities of heroin and morphine seized in Europe were quantities of heroin and morphine seized in East and reported in South-Eastern Europe by Turkey (62 per cent South-East Asia also continued to decline, in parallel of the European total), followed by Bulgaria, reflecting with ongoing declines in opium and heroin production the ongoing use of the Balkan route; the largest quanti- in the subregion. The largest quantities of heroin and ties seized in Western and Central Europe were reported morphine intercepted in East and South-East Asia in 2019 by Belgium, followed by the Netherlands, France, Ger- were again reported by China, which accounted for more many, the United Kingdom, Slovenia and Italy; and the than half (59 per cent), followed by Viet Nam, Thailand, largest quantities seized in Eastern Europe were reported Malaysia and Myanmar. The decline in the quantities of by Ukraine, followed by Belarus and the Russian Feder- heroin seized is also in line with reports of persistent ation. In all the subregions of Europe, more countries decreases in the demand for opiates in East and South- reported increases than decreases in the quantities of East Asia, including in China, as reflected in the number heroin and morphine seized in 2019. of registered drug users in that country.261 Quantities of opiates seized stabilized in By contrast, the amount of opiates seized in other subre- the Americas in 2019 gions of Asia (8 per cent of the global total) increased in 2019, reflecting increases in South Asia (notably India), The quantities of heroin and morphine seized in the Central Asia (notably Kazakhstan) and Transcaucasia Americas remained stable in 2019, although they were (notably Azerbaijan). Preliminary data based on indi- more than double those seized a decade earlier. Opiate vidual drug seizures suggest that the upward trend in trafficking remained concentrated in North America, the quantities of heroin and morphine seized may have with the quantities of heroin and morphine seized in the continued in South Asia in 2020.262 subregion accounting for 92 per cent of the total quan- tity seized in the Americas in 2019. Seizures made in the United States alone accounted for 83 per cent of the total quantity seized in the region that year. This was followed, in descending order of quantities seized, by Mexico (the 259 Information made available to the Subcommission on Illicit Drug Traffic and Related Matters in the Near and Middle East at its meet- country where most opium is produced in the region), ings during the extraordinary sessions of the subsidiary bodies of the Ecuador, Colombia, Canada and Guatemala. Commission on Narcotic Drugs, held online on 1 and 2 October 2020. 260 UNODC, Drugs Monitoring Platform. 261 See the chapter, “Demand for opioids”, in the present booklet. 90 262 UNODC, Drugs Monitoring Platform. Quantities of opiates intercepted in Africa are not Tanzania). The largest quantities of heroin and morphine large but have increased in recent years seized in West Africa (7 per cent of the African total) were 3 At close to 4 tons in 2019, the quantities of heroin and reported by Nigeria, followed by Benin. morphine intercepted in Africa accounted for about Despite the onset of the COVID-19 pandemic, traffick- 3 per cent of the global quantities of heroin and mor- ing continued in 2020, and large quantities of heroin phine seized. This was double the quantities seized a were reported seized by the United Republic of Tanzania, year earlier and represented a sevenfold increase over including a seizure of 270 kg of heroin from traffickers those seized in 2009; more than 99 per cent was in the from Nigeria and the United Republic of Tanzania in Dar form of heroin. es Salaam in April 2020, and 342 kg of heroin from a truck The vast majority of the heroin and morphine seized in that had travelled from Mozambique to South Africa in Africa in 2019 was reported in North Africa (91 per cent September 2020.263 Seizures of smaller amounts were of the total quantity seized in the region), most notably reported by other countries in sub-Saharan Africa (Benin, in Egypt, which accounted for 83 per cent of all heroin Côte d’Ivoire, Ghana, Kenya, , Malawi, Nigeria and morphine seized in Africa in 2019, followed by South- and Uganda) and in North Africa (Egypt, Morocco and ern Africa (6 per cent of the regional total, most notably Tunisia).264 Mozambique). The largest quantity of heroin seized in Supply of opiates Supply of OPIOIDS | East Africa (1 per cent of the regional total) was reported Continuous decline in quantities of opiates seized by Kenya. in Oceania Over the period 2009–2019, the largest quantities of In 2019, the quantities of heroin and morphine seized heroin and morphine seized in Africa were seized in North in Oceania decreased for the fourth year in a row and Africa (52 per cent of the total, most notably in Egypt), reached their lowest level since 2009. Australia accounts followed by East Africa (37 per cent of the total, most for more than 99 per cent of all the heroin and morphine notably in Kenya, followed by the United Republic of intercepted in the region.

Fig. 73 Quantities of heroin and morphine seized, by region, 2009–2019

140,000 35,000

120,000 30,000

100,000 25,000

80,000 20,000

60,000 15,000

40,000 10,000 Seizures in Asia (kilograms)

20,000 5,000 Oceania (kilograms) and

0 0 Seizures in Europe, Americas, Africa 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Asia Europe, Americas, Africa and Oceania Near and Middle East/South-West Asia Europe East and South-East Asia Americas Other Asia Africa Oceania

Source: UNODC, responses to the annual report questionnaire. 263 UNODC, Drugs Monitoring Platform. 264 UNODC, Drugs Monitoring Platform; and information provided by the UNODC Regional Office for West and Central Africa. 91 Map 2 MainMain heroin opiate tracking trafficking ‘ows as described flows, by reported 2015–2019 seizures, 

EASTERN EUROPE

NORTH AMERICA WESTERN AND CENTRAL TRANSˆ CENTRAL EUROPE SOUTH-EASTERN CAUCASIA ASIA NORTH AMERICA EUROPE EAST ASIA

SOUTH WEST SOUTHˆWEST ASIA NORTH ASIA AFRICA GULF AREA SOUTH AND ASIA MIDDLE EAST MEXICO & WEST AND CENˆ CENTRAL TRAL AFRICA AMERICA SOUTH-EAST ASIA

SOUTH EAST AMERICA AFRICA

SOUTHERN AFRICA

WORLD DRUG REPORT 2021 REPORT DRUG WORLD Global heroin tracking routes by amounts seized estimated on the basis of reported seizures,  OCEANIA Low volume ow

High volume ow

Sources: UNODC. The size of the route is based on the total amount seized on that route, according to the information on trafficking routes provided by Member States in the annual report questionnaire, individual drug seizures and The size of the route is based on the total amount seized on that route, according to the information on tra cking routes provided by Member States in the annual report questionnaire, individual drug seizures and other o cial documents, over the  period. The routes are determined on the basis of reported country of departure/ other officialtransit documents,and destination in these over sources. the As such, 2015–2019 they need to be consideredperiod. as Thebroadly routes indicative of are existing determined tra cking routes while on several the secondarybasis ofroutes reported may not be re‚ected. country Route arrows of departure/transit represent the direction of tra cking: and origins destination of the arrows indicate in these either the sources. area of departure As orsuch, the one ofthey last provenance, need toend pointsbe considered of arrows as broadly indicativeindicate of existing either the area trafficking of consumption orroutes the one of whilenext destination several of tra cking. secondary Therefore, the routes tra cking may origin may not not bere‚ect reflected. the country in which Route the substance arrows was produced.represent Please see the the Methodologydirection section of of trafficking: this document. origins of the arrows indicate either the area of departure or the one of last provenance,The boundaries end and namespoints shown of and arrows the designations indicate used on this either map do notthe imply area o cial ofendorsement consumption or acceptance byor the the United one Nations. of next destination of trafficking. Therefore, the trafficking origin may not reflect the country in which the substance was produced.

Map 3 Main countries identified as source and transit of heroin Map 4 Main countries identified as source and destination of heroin shipments, as described by reported seizures, 2015–2019 Main countries identiedshipments, as source and destination of asheroin shipments,described as described by reportedby reported seizures,   seizures, 2015–2019

Main countries mentioned as Main countries mentioned as source* of the shipment source* of the shipment Main countries mentioned as Main countries mentioned as transit* of the shipment destination* of the shipment Not main countries of source Not main countries of source or transit or destination

Sources: UNODC. Sources: UNODC.

* A darker shade indicates a larger amount of heroin being seized with the country as source/destination of the shipment, according to the information on tracking routes provided by Member States in the annual report questionnaire, individual drug seizures and other ocial documents, over the  period. The source may not re‚ect * A darker shade indicates a larger amount of heroin being seized with the country as source/destination of the shipment, according to the information on tracking routes provided by Member States in the annual report questionnaire, individual drug seizures and other ocial documents, over the  period. The source may not re‚ect *the countryA darker in which the substance shade was produced. The indicatesmain countries mentioned as sourcea largeror transit were identiƒed amount on the basis of both the of number heroin of times they were identiƒed being by other Member seized States as departure/transit with of seizures,the and thecountry annual average amount as that these source/destination seizures represent during the  period. For more details *the countryA darkerin which the substance shade was produced. The indicatesmain countries mentioned as sourcea largeror destination were identiƒedamount on the basis of both of the number heroin of times they were being identiƒed by other seized Member States as departure/transitwith the or destination country of seizures, and the annual as average source/destination amount that these seizures represent during the  on the criteria used, please see the Methodology section of this document. period. For more details on the criteria used, please see the Methodology section of this document.

ofThe boundaries the and shipment,names shown and the designations according used on this map do not imply ocialto endorsementthe informationor acceptance by the United Nations. A disputeon exists trafficking between the Governments of Argentina routes and the United provided andby Northern Member Ireland concerning sovereignty States over the Falkland in Islands the (Malvinas). The dotted line ofThe boundaries the and shipment,names shown and the designations according used on this map do not imply ocialto endorsementthe informationor acceptance by the United Nations. A disputeon exists trafficking between the Governments of Argentina routes and the United provided Kingdom of Great Britain andby Northern Member Ireland concerning sovereignty States over the Falkland in Islands the (Malvinas). The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The ƒnal status of Jammu and Kashmir has not yet been agreed upon by the parties. annualrepresents approximately report the Line of Control inquestionnaire, Jammu and Kashmir agreed upon by India and individual Pakistan. The ƒnal status of Jammu drug and Kashmir seizures has not yet been agreed uponand by the parties. other official documents, over the 2015–2019 annual report questionnaire, individual drug seizures and other official documents, over the 2015–2019 period. The source may not reflect the country in which the substance was produced. The main countries period. The source may not reflect the country in which the substance was produced. The main countries mentioned as source or transit were identified on the basis of both the number of times they were mentioned as source or destination were identified on the basis of both the number of times they were identified by other Member States as departure/transit of seizures, and the annual average amount that identified by other Member States as departure/transit or destination of seizures, and the annual average these seizures represent during the 2015–2019 period. amount that these seizures represent during the 2015–2019 period.

Source: UNODC elaboration. 92 Note: See the online methodological annex to the present report for more details. The boundaries and names shown and the designations used on these maps do not imply official endorsement or acceptance by the United Nations. A dispute exists between the Governments of Argentina and the United Kingdom of Great Britain and Northern Ireland concerning sovereignty over the Falkland Islands (Malvinas). The dotted line represents approximately the Line of Control in Jammu and Kashmir agreed upon by India and Pakistan. The final status of Jammu and Kashmir has not yet been agreed upon by the parties. Opiate trafficking routes a total of 1 ton. By comparison, countries in Western and Central Europe seized a total of 9 tons in 2019. 3 Opiate trafficking continues to be dominated by opiates originating in Afghanistan According to the authorities of the Islamic Republic of The main opiate trafficking flows continue to depart Iran, most of the heroin and morphine trafficked from from Afghanistan, the country where the vast major- Afghanistan transits Pakistan before reaching the Islamic ity of global opiate production takes place. These flows Republic of Iran. In 2018, 90 per cent of the morphine supply markets in neighbouring countries, most notably and 85 per cent of heroin seized in the Islamic Republic Iran (Islamic Republic of), Pakistan, countries in Central of Iran had transited Pakistan and only a small proportion Asia and India, as well as countries in Europe, the Near had been smuggled directly from Afghanistan. Heroin and Middle East, South Asia and Africa. Small proportions is mostly trafficked by land into and out of the Islamic are smuggled to South-East Asia and Oceania. Some 83 Republic of Iran (95 and 97 per cent, respectively, in 2019). per cent of the total global quantities of heroin and mor- Typically, heroin is then smuggled to Turkey or to coun- phine seized in 2019 were related to opiates produced tries in the Caucasus (75 per cent of all heroin seized in in Afghanistan. the Islamic Republic of Iran in 2018) and, to a far lesser extent, to Gulf countries (5 per cent of seizures in 2018). The remainder is used domestically (20 per cent in 2018). Most opiates are trafficked along the Balkan route opiates Supply of OPIOIDS | These patterns seem to have remained the same in 2019 and its various branches and 2020.267 The world’s single largest heroin trafficking route con- tinues to be the Balkan route, along which opiates are In Turkey, heroin is mainly trafficked from the east to the smuggled from Afghanistan to the Islamic Republic of west of the country.268 On the basis of preliminary data Iran, Turkey, the Balkan countries and various destina- on individual drug seizures, it appears that, in addition to tions in Western and Central Europe. Excluding seizures ongoing heroin seizures in the east of the country, around made in Afghanistan, countries along the Balkan route and near the border with Bulgaria, some signif- accounted for 50 per cent of the total global quantities icant seizures of heroin were also made near the border of heroin and morphine seized in 2019, with a further 7 with the Syrian Arab Republic in 2020,269 suggesting that per cent reported by countries in Western and Central some heroin is also trafficked through that country in Europe, of which a significant proportion was trafficked order to avoid controls along the border between the along the Balkan route. Based on mentions of countries Islamic Republic of Iran and Turkey. of origin, departure and transit by countries in Western and Central Europe, more than 70 per cent of the heroin From Turkey, heroin is then typically trafficked along the in Western and Central Europe seems to have transited Balkan route to Western and Central Europe, either along the Balkan route over the period 2015–2019, some 18 the western branch of the route via Bulgaria to various per cent transited the southern route and 7 per cent the western Balkan countries and then to markets in West- northern route, while 3 per cent may have originated in ern and Central Europe or, to a lesser extent, along the South-East Asia.265, 266 eastern branch of the route, which goes via Bulgaria and then to Romania, Hungary and other markets in Western In 2019, the largest quantities of heroin and morphine and Central Europe. intercepted along the Balkan route were, as in previous years, reported by the Islamic Republic of Iran (36 tons). Heroin trafficking across the Caucasus gained in Turkey reported seizing 20 tons and the Balkan countries importance prior to 2019 Heroin and morphine seized in the three Caucasus coun- 265 UNODC, responses to the annual report questionnaire. tries rose from 0.3 tons in 2017 to 1.9 tons in 2019, with 266 This finding should be treated with caution as some countries report the occurrence of “white heroin”, which they assume must have most of it reported by Azerbaijan, close to the coun- originated in South-East Asia, although there is evidence that in try’s borders with the Islamic Republic of Iran. From the past two decades “white heroin” has also been manufactured in Afghanistan for export purposes. Sources: U. Zerell, B. Ahrens and P. Gerz, “Documentation of a heroin manufacturing process in Afghan- istan”, in Bulletin on Narcotics, vol. LVII, Nos. 1 and 2 (United Nations 267 UNODC, Drugs Monitoring Platform. publication, 2005); and UNODC, responses to the annual report 268 UNODC, responses to the annual report questionnaire. questionnaire. 269 UNODC, Drugs Monitoring Platform. 93 Azerbaijan, heroin is typically either trafficked to mar- route in recent years, from 1 ton in 2017 and 1.9 tons in kets in the Russian Federation or to Georgia, and then 2018 to 4.5 tons in 2019.273 across the Black Sea to markets in Western and Central Europe. Georgia reported that 70 per cent of the heroin That increase is linked mainly to the use of the northern that entered the country in 2018 had transited Azerbaijan route by trafficking groups from outside the subregion, and 20 per cent had transited Armenia. Georgia reported who make use of citizens from various countries to traffic that 90 per cent of the heroin that entered the country heroin on trucks via the Islamic Republic of Iran and coun- in 2019 did so by land, and the rest by air. tries in Central Asia, but also via the Russian Federation and Belarus, to final destinations in Western and Central A temporary increased importance of the Caucasus Europe. Examples of this trafficking pattern include: 670 region as a trafficking route for supplying opiates to mar- kg of heroin originating in Afghanistan, which was seized kets in the Russian Federation was identified in 2018, in May 2019 in Frankfurt an der Oder, Germany, on a when 40 per cent of the heroin found on the Russian truck on the way from Kyrgyzstan to Belgium driven by market was reported to have transited Azerbaijan, up a Turkish national living in Kyrgyzstan; 1.1 tons of heroin from 30 per cent in the previous year.270 In 2019, however, seized in Kazakhstan on a truck that had departed the the Russian Federation no longer identified Azerbaijan Islamic Republic of Iran for a final destination in Germany, among the three main departure countries of heroin which involved nationals from Germany, Iran (Islamic found on its territory. Instead, those three countries were Republic of), the Netherlands, Poland, Serbia and Turkey; WORLD DRUG REPORT 2021 REPORT DRUG WORLD Afghanistan, Tajikistan and Kazakhstan. Moreover, the and the seizure of 550 kg of heroin in Minsk, Belarus, in primary destination for heroin seized in Azerbaijan in November 2019 that had been trafficked via the north- both 2019 and 2020 was Ukraine, followed by Georgia ern route for onward trafficking to the European Union, and a number of countries in Western and Central Europe, again involving a number of foreign nationals.274 Seizures not the Russian Federation.271 Nonetheless, while the along the northern route of large heroin shipments des- importance of the Caucasus route for supplying heroin tined for Western and Central Europe were not reported to the Russian Federation may have declined, a number in 2020, however. of heroin seizures made in 2019 and 2020 in the North Caucasian Federal District of the Russian Federation, in Increasing quantities of opiates are being trafficked particular close to seaports, suggest that heroin contin- along the southern route, including to South Asia and ues to be trafficked through the Caucasus, albeit in small Europe quantities, or is trafficked via either the Caspian Sea or The southern route includes an array of other trafficking the Black Sea to the Russian Federation.272 routes running mostly south from Afghanistan. Opiates are mainly trafficked along the route via Pakistan and/ Trafficking in heroin along the northern route or via the Islamic Republic of Iran to India, for domestic may have increased in 2019 while decreasing to consumption and re-export to countries in the region, final destinations in the Russian Federation and to Africa, for local markets and re-export to Europe. Trafficking in heroin along the northern route, which Seizures of heroin and morphine reported by countries goes from Afghanistan, through Central Asia mainly to along the southern route (excluding Pakistan) rose from markets located in the Russian Federation, has decreased 2.7 tons in 2015 to 9.4 tons in 2019; their overall share of substantially compared with two decades ago, when the the global quantities of seized opiates that resulted from heroin and morphine seized in countries along the route opium produced in Afghanistan rose from 3 per cent in amounted to more than 10 tons and represented more 2015 to 8 per cent in 2019. than 10 per cent of global seizures of those opiates traf- ficked from Afghanistan. The proportion was 4 per cent in Some of this increase has been linked to an increase in 2019, up from just 1 per cent in 2018, reflecting an increase opiate shipments from South-West Asia to South Asia. in the quantities of heroin seized along the northern Data on the prevalence of the use of opiates suggest that South Asia (most notably India) may be home to the larg- est number of opiate users worldwide (17 million people, 270 UNODC, responses to the annual report questionnaire. 271 UNODC, Drugs Monitoring Platform. 273 UNODC, responses to the annual report questionnaire. 94 272 Ibid. 274 UNODC, Drugs Monitoring Platform. Fig. 74 Distribution of quantities of heroin and morphine seized, by Although to a far lesser extent, South Asia continues main trafficking routes, 2009–2019 to receive heroin shipments from neighbouring Myan- 3

) 100 mar (less than 1 per cent of total heroin seized in India

e 4 4 7 5 5 9 6 5 7 8 and 5 per cent of the total heroin seized in Bangladesh 8 7 12 7 t a g 7 3 8 11 8 n 9 1 12 1 1 3 9 in 2019 originated in Myanmar). However, while Ban- e 6 6 3 c 8 2 4 6 1 r 80 3 3 2 14 4 4 gladesh reported that 95 per cent of the heroin seized e 4 11 5 17 7 8 p 11 ( 13 9 5 19 in the country in 2019 originated in India, the origin of s 3 e 25 12 r 8 significant amounts of heroin seized in India remains u 60

z 25 i 19 unknown. Some of the opiates seized in India may be of e 31 s 4 33 25 48 domestic origin, either from diversion from the country’s

a l 58 b 52 4 o 40 licit opium production or from illicit opium poppy cul-

l 39 3 48 g 2

f tivation in the hilly and largely inaccessible areas in the

o 4 37

n 49 north (Arunachal Pradesh, Bihar, Manipur, , o 20 41 7 ti 35 r 9 33 Jharkhand, Jammu and Kashmir and Himachal Pradesh), o 7 6 27 p 5 16 where the authorities eradicated more than 10,000 acres

o 7 r 10 9 10 6 277 P 0 3 (slightly more than 4,000 ha) of opium poppy in 2019. Supply of opiates Supply of OPIOIDS |

2 0 9 2 0 1 2 0 1 2 0 1 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6 2 0 1 7 2 0 1 8 2 0 1 9 Although countries in Western and Central Europe are Americas mostly supplied by heroin trafficked via the Balkan route, South-East Asia and Oceania the use of the southern route is not uncommon. Of all Northern route reported mentions of origin, departure and transit by Southern route countries in Western and Central Europe in relation Pakistan Balkan route to heroin, 18 per cent referred to trafficking along the Western and Central Europe southern route over the period 2015–2019, mainly via Afghanistan Southern and East Africa (notably South Africa, , Seizures related to Afghan opiates Mozambique, Kenya, Uganda, Madagascar and United Republic of Tanzania), the Gulf countries (notably Qatar Source: UNODC, responses to the annual report questionnaire. and United Arab Emirates) and India. Notes: The Balkan route includes: the Islamic Republic of Iran, half of Transcaucasia, South-Eastern Europe; the southern route includes: South Asia, Gulf countries and other countries in the Near and The two European countries reporting seizing the largest Middle East and Africa; and the northern route includes: Central Asia, Eastern Europe and half of Transcaucasia. Heroin seized in Transcaucasia was attributed partly to the Balkan route and partly to the quantities of heroin that had been trafficked along the northern route as it may supply both routes. southern route in the period 2015–2019 were Belgium (via Burundi, Ethiopia, South Africa, Uganda, Kenya, Tan- zania and Rwanda) and Italy (mostly by air via Pakistan, or 39 per cent of the global estimate in 2019, i.e., far more Qatar, the United Arab Emirates, South Africa, Ethiopia, than in any other subregion) and may have experienced Madagascar and Oman). In 2019, most (98 per cent) of very strong increases in opiate use over the past two the heroin seized in Belgium arrived by ship from the decades.275 Significant quantities of the opiates needed Islamic Republic of Iran. By contrast, most (84 per cent) to meet domestic demand in South Asia are likely to be of the heroin seized in Italy in 2019 arrived by air, mainly smuggled from South-West Asia; for example, 40 per via Ethiopia, Oman, Pakistan, South Africa and the United cent of the total quantity of heroin seized in India in 2019 Arab Emirates; this stands in contrast to the previous came from South-West Asia.276 In 2019, India reported a year, when most (60 per cent) of the heroin seized in Italy particularly strong increase (157 per cent) in heroin ship- arrived by sea, mostly from the Islamic Republic of Iran. ments from South-West Asia by sea. The single largest seizure linked to trafficking along the southern route in 2020 appears to have been a ship- 275 Opioid use among men in India was reported to have increased from ment of 1.1 tons of heroin, found in a container on a ship a rate of 0.7 per cent in 2004 to 3.97 per cent in 2018; much of this increase resulted from an increase in the use of heroin (Source: Atul docked at the port of Felixstowe, United Kingdom, in Ambekar and others, Magnitude of Substance Use in India 2019 (New Delhi, Ministry of Social Justice and Empowerment, 2019)). 276 UNODC, responses to the annual report questionnaire. 277 Ibid. 95 September 2020, which had been en route to Antwerp, Most of the heroin trafficked in the Americas Belgium, with the final destination being a warehouse continues to come from within the region 278 in the Hague, the Netherlands. A year prior to that, in The main opiate trafficking flows in the Americas con- September 2019, a similar seizure had also been made in tinue to start from key production areas in Latin America, Felixstowe, when 1.3 tons of heroin were discovered in a principally Mexico and, to a far lesser extent, Colombia container on a ship from Pakistan that was destined for and Guatemala. Heroin originating in those countries 279 a warehouse in Rotterdam, the Netherlands. accounts for most of the heroin supplied to the United States and also supplies the still-small heroin markets Heroin trafficking is on the decline in East and of South America. Canada, by contrast, continues to be South-East Asia, although the subregion still supplies supplied mainly by heroin from South-West Asia.282 Oceania The main trafficking activities related to opiates from Most heroin (and morphine) trafficking in the Americas South-East Asia concern opiates produced within the takes place within North America, from Mexico to the subregion itself (mostly in Myanmar and, to a lesser United States and, to a far lesser extent, from Colombia extent, the Lao People’s Democratic Republic), which and Guatemala, typically via Mexico, to the United States. are trafficked to other markets in East and South-East Most of the samples of heroin analysed in the United Asia (mostly China and Thailand) and Oceania (mostly States in 2018 originated in Mexico (93 per cent), while

WORLD DRUG REPORT 2021 REPORT DRUG WORLD a small proportion originated in South America (2 per Australia). The quantities of drugs reported seized by countries in East and South-East Asia and Oceania fell, cent) or was classified as of “inconclusive South Ameri- from 13.3 tons in 2015 to 11 tons in 2019, pointing to a can” origin (4 per cent). There has thus been a substantial possible decline in heroin trafficking in that part of the increase over the last decade in the share of the heroin world. That decline went in parallel with a reduction of samples in the United States originating in Mexico (38 more than 20 per cent in opium production in Myanmar per cent in 2008) at the expense of those originating in 283 over the period 2015–2019.280 South America (59 per cent in 2008).

The main embarkation point for heroin seized at the Aus- On the basis of the quantities seized, heroin traffick- tralian border in the fiscal year 2018/19, measured by ing within the Americas, including in North America, weight, was Malaysia, followed by (in descending order remained stable in 2019 compared with the previous of the weight seized) Thailand, the Lao People’s Demo- year, at about 10 tons, although that is more than double cratic Republic, , Iraq, South Africa, Pakistan, the quantity seized a decade earlier. Expressed as a per- Mozambique, Indonesia and India, pointing to South- centage of the global quantities of heroin and morphine East Asia as the origin of most of the heroin in Australia. seized, the share seized in the Americas increased from This is in contrast to the situation a decade ago, when 4 per cent in 2009 to 8 per cent in 2019. the proportion of heroin trafficked from South-East Asia was much smaller, accounting for 26 per cent of the total quantity seized at the Australian border in 2008. It has risen since then, to almost 100 per cent in 2018 and 92.5 per cent over the first two quarters of 2019 when, for the second time in the past decade, heroin from South America (7 per cent) was reported to have been seized at the Australian border.281

278 National Crime Agency, “NCA investigation keeps 120-m Class A drugs haul off UK streets”, 18 September 2020. 279 BBC News, “Heroin worth £120m found at Felixstowe in ‘UK’s biggest haul’”, 4 September 2019. 280 UNODC, Myanmar Opium Survey 2020: Cultivation, Production, and 282 UNODC, Drugs Monitoring Platform. Implications, and previous years. 283 United States, Drug Enforcement Administration and Office of Foren- 281 Australian Criminal Intelligence Commission, Illicit Drug Data Report sic Sciences, “The 2018 Heroin Signature Program”, Joint Intelligence 96 2018–19 (Canberra 2020), and previous years. Report (April 2020). OPIOIDS 3

reached a peak in recent years, first in 2014 and again Supply of other opioids in 2019, when they tripled compared with the previous year. With a total amount of 228 tons of pharmaceuti- The majority of the opioids in terms of quantities seized cal opioids seized, an all-time high was reached in 2019, that are not opiates that end up on illegal drug markets exceeding the quantities of opiates seized if converted continue to be licitly manufactured opioids that have into heroin equivalents: 96 tons of heroin, 26 tons of been diverted from licit to illicit channels. Nowadays, morphine and 73 tons of opium expressed in heroin diversions at the international level are limited, how- equivalents. ever.284 The diversion of pharmaceutical opioids is more common at the national level; they are either sold on In the past five years, tramadol, an opioid not under inter- the street or are obtained through doctor shopping or national control, has accounted for nearly two thirds of falsified prescriptions for the acquisition of opioids from the global quantities of pharmaceutical opioids seized.

the legal supply chain, in particular from pharmacies. The Codeine accounted for a third and fentanyls for less than other opioids Supply of OPIOIDS | pharmaceutical opioids reported to have been diverted 2 per cent. In 2019, however, one year after India had most frequently over the period 2015–2019 were tra- put tramadol under national control, the largest quanti- madol in Africa; codeine in Asia (mostly in the form of ties of pharmaceutical opioids seized worldwide were of cough syrups), followed by tramadol; oxycodone in the codeine (65 per cent of the total), followed by tramadol Americas, followed by hydrocodone; buprenorphine in (26 per cent) and fentanyl (2 per cent). A number of other Europe, followed by methadone and tramadol; and mor- opioids were seized in 2019, including methadone, vari- phine in Oceania, followed by oxycodone and codeine.285 ous mixtures containing fentanyl, licit or pharmaceutical morphine, , pethidine, oxycodone, carfen- Some opioids, such as fentanyl and its analogues, and tanil, buprenorphine, hydromorphone, , also tramadol and methadone, are not only diverted , hydrocodone, diphenoxylate and pentaz- from licit sources but also manufactured for the illicit ocine. In addition to a number of substances seized in drug market in semi-legal laboratories or fully clandes- previous years, including , isometh- tine laboratories. The largest numbers of clandestine adone, hydromorphine, , dihydrocodeine, synthetic opioid laboratories reported to have been dis- apo-oxycodone, U-47700, , mantled over the period 2015–2019 were manufacturing and oxymorphone. fentanyl (20 laboratories, mostly in North America and, to a lesser extent in Europe and Oceania), methadone (7 In 2019, increases in the quantities of pharmaceutical laboratories, mostly in Eastern Europe) and carfentanil opioids seized compared with 2018 were reported not (3 laboratories, all in North America).286 only for codeine but also for a number of other opioids, in particular fentanyl and several of its analogues (including Global quantities of pharmaceutical opioids carfentanil and ), as well as methadone, seized have reached a record high morphine, pethidine, oxycodone, hydromorphone and hydrocodone. The quantities of tramadol, by contrast, 287 The quantities of pharmaceutical opioids seized have continued declining in 2019 and were less than half those seized in 2017. 284 INCB, Report of the International Narcotics Control Board for 2019 (E/INCB/2019/1). 285 UNODC, responses to the annual report questionnaire. in veterinary medicine. Among the fentanyl analogues approved as 286 Ibid. pharmaceutical drugs for human use are , fentanyl, remifen- 287 Substances reported by Member States in their responses to the tanil and . One (carfentanil) is approved for veterinary use. UNODC annual report questionnaire under the category “phar- Under this category, some Member States also report substances maceutical opioids”. Not all of these substances, however, are (such as furanylfentanyl) that are, in general, not approved for med- necessarily intended for medical use in humans; some are also used ical use. 97 Fig. 75 Global quantities of pharmaceutical opioids Fig. 76 Global quantities of pharmaceutical opioids seized, 2009–2019 seized and geographical distribution, 2015–2019 Quantities seized 200 160 140 150 120 100 100 80

Ton equivalentsTon 60 50 equivalentsTon 40 20 0 0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2015 2016 2017 2018 2019

Other pharmaceutical opioids Africa Asia Americas Europe Oceania WORLD DRUG REPORT 2021 REPORT DRUG WORLD Fentanyl and analogues Codeine Tramadol Geographical distribution 100 Source: UNODC, responses to the annual report questionnaire. Notes: The data refer to seizures of opioids reported by Member States to UNODC 80 in the annual report questionnaire under the category “pharmaceutical opioids”. Not all of these substances, however, are necessarily intended for medical use in humans; some are also used in veterinary medicine. Among the fentanyl analogues 60 approved as pharmaceutical drugs for human use are alfentanil, fentanyl, and sufentanil. One (carfentanil) is approved for veterinary use. Some Member States also report substances (such as furanylfentanyl) that are, in general, Percentage 40 not approved for medical use. 20

Analogues of fentanyl that were seized over the period 0 2009–2019 include carfentanil, acetyl-alpha-methylfen- 2015 2016 2017 2018 2019 tanyl, , furanylfentanyl and sufentanil. Africa Asia Americas Europe Oceania Data indicate the dominance of Africa and Asia in the global quantities of pharmaceutical opioids seized. Over Source: UNODC, responses to the annual report questionnaire. the period 2015–2019, the proportion seized in Africa declined, in line with the decrease in the quantities of tramadol seized at the global level, while the propor- tion seized in Asia increased, in line with the increasing accounted for 39 per cent of pharmaceutical opioids amounts of codeine seized. seized in 2019, a figure that rises to 52 per cent when all the different fentanyl mixtures and analogues are The breakdown of substances seized looks different, how- included. In terms of the quantities of pharmaceutical ever, once the form of the substances (tablets versus opioids seized, adjusted for purity and transformed into syrups) and the typical purity of the quantities seized S-DDDs, fentanyl and its analogues were followed by are considered and transformed into daily defined doses codeine (19 per cent of the total), tramadol (16 per cent) (S-DDDs).288 This calculation suggests that fentanyl and methadone (4 per cent).

288 S-DDDs refers to “defined daily doses for statistical purposes” as prescription doses. Details of the S-DDDs used for these calculations defined by INCB. They are technical units of measurement for the and of the purity adjustments made are provided in the methodologi- 98 purposes of statistical analysis and are not recommended daily cal annex in the online version of the present report. Fig. 77 Global quantities of pharmaceutical opioids furanylfentanyl and sufentanil.289 In 2019, the largest seized, adjusted for purity and expressed in quantities of fentanyls seized at the global level were of 3 S-DDDs, 2019 fentanyl, followed by mixtures of fentanyl and carfent- anil, a substance that is 10,000 times more potent than 601 290 600 morphine. The vast majority of the fentanyls (98 per cent) seized over the period 2015–2019 were intercepted 500 in the Americas, almost all of them in North America. The proportions seized in Europe (1.3 per cent, mostly in

S- DD D 400 f

o 295 Eastern Europe) and Asia (0.4 per cent, mostly in East and s

n 300 241 South-East Asia) were comparatively very small. Although

illi o most of the increase in the amounts of fentanyls seized 200 M 127 134 over the period 2010–2019 was reported in North Amer- 100 69 55 ica, the quantities of fentanyls seized in Europe and Asia 5.0 2.4 0.2 0.2 0.1 also increased. In all regions, the quantities of fentanyl l 0 l r x i e e e e e e e i yl

o seized were larger than those of any fentanyl analogue. e n n n n n n n n i i i i d h a n o o o a t e - m h h d t i t h d At the same time, the sizeable amounts of mixtures of d p p n O y l n h a d o p r r e t r n am a e h f o o C o e r

t fentanyl seized in 2019 suggest that the market may be a r o y c F n t T P x e m e m n C a t r O M

i increasingly diversifying in terms of fentanyl products. o e p r c F i u L y d Supply of other opioids Supply of OPIOIDS | B H Most trafficking in fentanyls takes place from East Controlled at the interna�onal level and South-East Asia to North America, including via Not controlled at the interna�onal level Mexico Given the predominance of seizures in North America Sources: UNODC calculations based on: responses to the annual report and according to United States authorities, international questionnaire; INCB, Narcotic Drugs: Estimated World Requirements for trafficking in fentanyls over the period 2015–2019 took 2020 – Statistics for 2018 (E/INCB/2019/2); and INCB, Psychotropic Substances: Statistics for 2018 – Assessments of Annual Medical and place mainly from East and South-East Asia (notably Scientific Requirements (E/INCB/2019/3). China) to North America, either directly, in small quanti- Note: S-DDDs refers to “defined daily doses for statistical purposes” as defined by ties, to the United States or to Mexico, in large quantities, INCB. They are technical units of measurement for the purposes of statistical analysis and are not recommended daily prescription doses; actual doses may differ and from there to the United States or to Canada for based on treatments required and medical practices. Details of the S-DDDs used for the domestic market and/or for onward shipment to the these calculations and of the purity adjustments made are provided in the 291, 292, 293 methodological annex in the online version of the present report. United States. These trafficking patterns seem to have changed, how- ever, since the class scheduling of fentanyls in China in Huge increase seen in trafficking in May 2019,294, 295 which went hand in hand with a major fentanyls crackdown on illicit fentanyl laboratories and sales sites in China, together with improved training for law In recent years, the largest increases in the amounts of the various pharmaceutical opioids seized have been 289 The fentanyl analogues 3-methylfentanyl, acetyl-alpha-methylfenta- reported for fentanyl and its analogues. Compared with nyl, ocfentanil and furanylfentanyl are not pharmaceutical drugs. the previous year, the global quantities of fentanyls 290 WHO, “Carfentanil: critical review report – agenda item 4.8”, Expert Committee on Drug Dependence, thirty-ninth meeting, 6–10 November seized increased by more than 30 per cent in 2018 and 2017 (Geneva, 2017). more than 60 per cent in 2019. Moreover, the quantities 291 UNODC, responses to the annual report questionnaire. of fentantyls seized in 2019 were almost 50 times larger 292 United States, Department of Justice, Drug Enforcement Adminis- than those seized in 2015 and more than 6,000 times tration, 2019 National Drug Threat Assessment (December 2019), and previous years. larger than those seized in 2000. The largest quantities 293 United States, Department of State, Bureau for International of fentanyl-type substances seized over the period 2010– Narcotics and Law Enforcement Affairs, 2020 International Narcotics 2019 were reported for fentanyl as such, followed by Control Strategy Report, vols. I and II (March 2020). 294 UNODC, responses to the annual report questionnaire. various mixtures containing fentanyl, 3-methylfentanyl, 295 China, National Narcotics Control Commission, Drug Situation in carfentanil, acetyl-alpha-methylfentanyl, ocfentanil, China 2019 (Beijing, 2020). 99 Fig. 78 Global quantities of fentanyls seized, enforcement officials and the installation of new screen- 2010–2019 ing equipment at postal facilities.296 As a result, the amount of illicit fentanyl and fentanyl analogues shipped By substance by mail from China to the United States, which used to 5,000 be a major route for high-quality fentanyls arriving in the United States, appears to have decreased dramati- 4,000 cally, according to United States authorities.297, 298 In 2018, direct shipments of fentanyl analogues to the United 3,000 States by mail declined, in terms of quantities seized, by more than 50 per cent299 following the scheduling Kilograms of a number of fentanyl analogues in China in 2017300, 2,000 301 and 2018.302

1,000 Nonetheless, according to United States authorities, ship- ments of fentanyls from other countries (such as India) and/or of for the clandestine man- 0 ufacture of fentanyls from China and other countries to Mexico appear to have increased over the last two 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 WORLD DRUG REPORT 2021 REPORT DRUG WORLD years.303 In fact, there is a potential risk that criminal Other synthetic fentanyls groups operating in countries with a large and thriving Sufentanil pharmaceutical sector may become more involved in Furanylfentanyl the clandestine manufacture of fentanyls. In September Heroin/carfentanyl containing substance 2018, the Indian authorities reported a relatively large Ocfentanil seizure of fentanyl destined for organized crime groups in Acetyl-alpha-methylfentanyl Mexico that involved the arrest of a Mexican citizen.304, 305, Carfentanyl 306, 307 Moreover, United States authorities have reported 3-Methylfentanyl the interception of mail shipments containing illicitly Mixtures of fentanyl Fentanyl 296 Ibid. 297 United States, Department of Justice, Drug Enforcement Administra- By region tion, 2019 National Drug Threat Assessment (and previous years). 298 United States, Department of State, Bureau for International 5,000 Narcotics and Law Enforcement Affairs, 2020 International Narcotics Control Strategy Report. 4,500 299 United States, Department of Justice, Drug Enforcement Administra- 4,000 tion, 2019 National Drug Threat Assessment. 300 UNODC, Laboratory and Scientific Section Portals, “China: carfent- 3,500 anil, furanylfentanyl, acrylfentanyl and placed under 3,000 national control”, February 2017. 301 United States, Department of Justice, Drug Enforcement Adminis- 2,500 tration, “China announces scheduling controls of new psychoactive

Kilograms 2,000 substances/fentanyl-class substances” (19 June 2017). 302 UNODC, Laboratory and Scientific Section Portals, “China places 1,500 additional 32 new psychoactive substances under national control”, August 2018. 1,000 303 United States, Department of Justice, Drug Enforcement Administra- 500 tion, 2019 National Drug Threat Assessment. 304 India, , “Drug situation report/significant 0 event report for India for the month of September 2018” (New Delhi, September 2018).

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 305 United States, Department of Justice, Drug Enforcement Administra- tion, 2019 National Drug Threat Assessment. Americas Europe Asia Oceania 306 United States, Department of State, Bureau for International Narcot- ics and Law Enforcement Affairs, 2019 International Narcotics Control Strategy Report. 100 Source: UNODC, responses to the annual report questionnaire. 307 UNODC, Drugs Monitoring Platform. with the Arellano Félix Organization (also known as the ) for such trafficking activities,310 and the 3 First illicit fentanyl laboratory Sinaloa Cartel. The Sinaloa Cartel and the Jalisco New dismantled in India Generation Cartel have previously been identified as According to authorities in the United States, the primary groups involved in trafficking fentanyls into in September 2018, the Directorate of Revenue the United States across the country’s south-western 311 Intelligence of India, in cooperation with the Drug border but, according to United States authorities, both Enforcement Agency of the United States, disman- cartels are also heavily involved in the smuggling of a 312 tled the first known illicit fentanyl laboratory in number of other drugs into the United States. India and seized several kilograms of fentanyl.a A To enable the import of fentanyl and/or of fentanyl close partnership was identified between an Indian precursors from Asia into Mexico, the control of the coun- and a Chinese national who worked in concert to try’s Pacific ports is of key importance to traffickers. The obtain fentanyl precursor chemicals and manufac- Sinaloa Cartel is active in many of the country’s northern ture fentanyl.b Pacific ports, while the Jalisco New Generation Cartel is 313 The operation had begun in China but later active in several of the country’s southern Pacific ports. moved to India after the actors involved encoun- This is of importance because Mexico continues to be a tered difficulties obtaining precursor chemicals major transit country for fentanyls, as well as a source in China, possibly as a consequence of the previ- country for illicit fentanyl and fentanyl-laced falsified ous announcement by China of the regulation of tablets destined for the United States market, according other opioids Supply of OPIOIDS | 314 fentanyl precursors 4-anilino-N-phenethyl-4-piper- to United States authorities. idone (4-ANPP) and N-phenethyl-4-piperidone In addition to seizures of fentanyl in territories under the (NPP). Subsequent investigations also indicated control of the Sinaloa Cartel and the Jalisco New Gener- that, in the meantime, chemists in India had devel- ation Cartel, seizures of fentanyl are also concentrated oped the expertise to illicitly manufacture fentanyl along the border between Mexico and the United States, without NPP and 4-ANPP.b in particular along the stretch between Mexico and the

a United States, Department of State, Bureau for International states of California and Arizona that is controlled by the Narcotics and Law Enforcement Affairs, 2020 International Sinaloa Cartel and the Arellano-Félix Organization, which Narcotics Control Strategy Report, vol. I (March 2020). has an alliance with the Jalisco New Generation Cartel, as b United States, Department of Justice, Drug Enforcement well as on the east coast of the United States, most nota- Administration, 2019 National Drug Threat Assessment (December 2019). bly in the north-eastern states, around the Great Lakes and in some parts of the Midwest. The number of opi- oid-related deaths in the United States involving fentanyl is also highest around the Great Lakes, the north-east imported pharmaceutical drugs, including fentanyl and and parts of the Midwest.315 fentanyl analogues, originating in India.308 Role of domestic groups in the trafficking of fentanyl Role of Mexican cartels in fentanyl trafficking to within the United States the United States While Mexican organized crime groups serve as suppliers Despite these developments, most fentanyl trafficking to the United States continues to be in the hands of orga- 310 UNODC, annual report questionnaire. nized crime groups involved in trafficking the drugs from 311 United States, Department of Justice, Drug Enforcement Administra- Mexico to the United States. The main drug trafficking tion, 2018 National Drug Threat Assessment. (October 2018). organizations involved include the Jalisco New Gener- 312 United States, Department of Justice, Drug Enforcement Administra- tion, 2017 National Drug Threat Assessment (October 2017). 309 ation Cartel, which now operates in a close alliance 313 Scott Stewart, “Mexico’s cartels find another game changer in fentanyl”, Stratfor, 3 August 2017. 308 United States, Department of State, Bureau for International 314 United States, Department of State, Bureau for International Narcotics and Law Enforcement Affairs, 2020 International Narcotics Narcotics and Law Enforcement Affairs, 2020 International Narcotics Control Strategy Report. Control Strategy Report, vol. I. 309 Chris Dalby, “The fentanyl trade through Mexico, explained in 8 315 United States, Department of Justice, Drug Enforcement Administration, graphs”, InSight Crime, 19 February 2019. 2019 National Drug Threat Assessment. 101 The Sinaloa Cartel, a major player in illicit fentanyl manufacture in Mexico According to authorities in the United States, most of the At the same time, significant quantities of fentanyl continue to fentanyl synthesis and fentanyl production operations be smuggled into Mexico for re-export to the United States.h dismantled in Mexico to date have occurred in territories In January 2019, the Ministry of Public Security reported the controlled by the Sinaloa Cartel.a interception of shipments of fentanyl from China and Hong Kong, China, at Mexico City International Airport.i In August For example, in November 2017, Mexican authorities seized 2019, the Ministry of Naval Affairs announced a major sei- a fentanyl laboratory in Culiacán, the state capital of Sinaloa zure of powdered fentanyl, which had originated in Shanghai, b and the home base of the Sinaloa Cartel. In September 2018, China, and was headed to Culiacán, by the Mexican navy and counter-narcotics authorities of Mexico and the United States customs enforcement personnel at the Lázaro Cárdenas sea- seized a laboratory in Baja California, Mexico, that was man- port.j The latest significant seizure was in February 2021, when c ufacturing fentanyl and carfentanil, arresting two suspected the Mexican military seized over 100,000 fentanyl tablets associates of the Sinaloa Cartel. In September 2018, police (together with over 2.5 tons of methamphetamine) from a in the border city of Mexicali raided a clandestine fentanyl vessel near the coast of the north-western state of Sinaloa.i laboratory and detained two suspects, including a Russian a United States, Department of Justice, Drug Enforcement Administration,

WORLD DRUG REPORT 2021 REPORT DRUG WORLD passport holder, underlining the international dimension of 2019 National Drug Threat Assessment (December 2019). d such activities. In December 2018, the Office of the Attorney b Steven Dudley and others, “Mexico’s role in the deadly rise of fentanyl” General of Mexico reported the dismantling of a clandestine (Washington D.C., Wilson Center Mexico Institute and InSight Crime, fentanyl laboratory in Mexico City,b which was also equipped 2019). d c United States, Department of State, Bureau for International Narcotics with an automated pill press. Mexican law enforcement and Law Enforcement Affairs, 2020 International Narcotics Control Strategy authorities also seized and dismantled clandestine fentanyl Report, vol. I (March 2020). pill-milling operations in 2018, one of which was responsible d AP News, “Mexico raids lab producing fentanyl in capital”, 13 December for producing carfentanil-laced tablets. Another laboratory, 2018. e Mexico, Sinaloa, Ministry of Public Security, “Comunicación SSPE/141/2019: dismantled in December 2018 by Mexican law enforcement Policía Estatal Preventiva y Fuerzas Armadas aseguran presumiblemente el agencies in Azcapotzalco, Mexico City, apparently produced primer laboratorio de fentanilo a nivel nacional”, 11 April 2019. fentanyl-laced oxycodone tablets.a f Mexico, Attorney General’s Office, “Comunicado FGR 183/19: FGR asegura en Sinaloa más de 33 mil pastillas de fentanilo, heroína y ácido clorhídrico”, In April 2019, Mexican authorities reported the dismantling of 17 April 2019. e g Mexico, Attorney General’s Office, “Comunicado FGR 294/19: FGR asegura a clandestine fentanyl laboratory in Culiacán, seizing not only en Nuevo León laboratorio posiblemente utilizado para elaborar fentanilo”, fentanyl tablets but also several containers that contained 16 June 2019. heroin.f In June 2019, authorities reported the dismantling of h Chris Dalby, “The fentanyl trade through Mexico, explained in 8 graphs”, InSight Crime, 19 February 2019. a clandestine laboratory in Nuevo León that had been used i UNODC, Drugs Monitoring Platform. for the manufacture of chemical precursors of fentanyl and j Robert Arce, “Major fentanyl shipment from China seized in Mexico”, possibly also the manufacture of fentanyl itself.g ChinaGate, 25 August 2019.

of wholesale quantities of fentanyl to domestic orga- A comparison of fentanyl seizures made at the nized crime groups across the United States, smaller, south-western border of the United States with those independent trafficking organizations in the United made in other parts of the country revealed that, despite States purchase fentanyl on the clear web directly from the identification of some fentanyl laboratories China and sell it in the United States over the darknet. in Mexico, most fentanyl contained in wholesale-level In addition, Dominican organized crime groups based in shipments does not contain mixtures of other drugs, the United States, which typically source fentanyl from suggesting that most of the mixing of fentanyl with Mexican organized crime groups, are heavily involved heroin and other illicit drugs continues to take place in in fentanyl trafficking in the country’s north-eastern the United States, not Mexico.317 states.316

102 316 Ibid. 317 Ibid. Map 5 Individual seizures of fentanyl and its analogues in North in various subregions, in particular North Africa, West America, January 2019–February 2021 Africa and the Middle East.321 3

Alaska (U.S.A.) Overall, 43 countries reported tramadol seizures over CANADA the period 2015–2019, including 23 countries in 2019, an increase from 14 countries in 2015 and 3 countries in 2010.

Reports from Member States reveal a total of 44 coun- tries identified as countries of origin, departure and transit of tramadol over the period 2015–2019,322 with UNITED STATES OF AMERICA India being the most frequently mentioned, followed by Nigeria, Egypt and the Russian Federation; among the 27 countries identified as countries of origin, the most frequently mentioned was India, followed by China. Reported destination countries included countries in Africa (mostly in West, Central and North Africa), Asia

Fentanyl seizures (kg) (mostly in the Near and Middle East), Europe and the January -February MEXICO ≤  Americas.  -   - 

Over the period 2015–2019, the largest quantities of tra- other opioids Supply of OPIOIDS |  - 

No data madol seized were reported in West and Central Africa, which accounted for 88 per cent of the global total. The Source: UNODC, Drugs Monitoring Platform. predominance of West and Central Africa in the global Note: The figure is based on information from individual seizures, which constitutes an opportunistically quantities of tramadol seized increased to 98 per cent in determined subset of all relevant seizures. 2019. The largest quantities seized in 2019 were reported in Benin, followed by Egypt and India, although the latter In 2018, 94 per cent of the fentanyl seized and analysed reported major decreases in 2019 compared with the in the United States had been synthesized using the more previous year, while Egypt reported major decreases com- sophisticated “Janssen method” and 6 per cent using the pared with 2017 and 2016. less sophisticated “Siegfried method”, suggesting that the manufacture of fentanyl, at least until 2018, was done by The global quantities of tramadol seized have increased highly trained and qualified chemists.318 markedly over the last decade, from less than 1 kg per year prior to 2010 and 7 kg in 2010 to a peak of 122 tons in 2017, with most of the quantities seized in that year being Trafficking in tramadol appears to have reported (in descending order of the amount seized) by declined in 2019 and trafficking in the drug Nigeria, Egypt and the United Arab Emirates. In 2018, remains concentrated in Africa the year that India put tramadol under national control, Tramadol, an opioid medication used to treat moderate the quantities of the drug seized declined in all subre- to (moderately) severe pain,319 is not under international gions other than South Asia to a global total of 76 tons. control but is under national control in a number of coun- In parallel, the number of countries reporting India as the tries in all regions. Given its dual properties as an opioid main source country for tramadol also declined in 2018. analgesic with energy- and mood-enhancement prop- In 2019, the amount of tramadol seized globally continued 320 erties, the non-medical use of tramadol has spread declining and reached a total of some 60 tons; that was only because some 59 tons were reported to have been seized by authorities in Benin during the first five months 318 Ibid. of that year.323 According to United States authorities, 319 WHO, “Tramadol: update review report – agenda item 6.1”, Expert Committee on Drug Dependence, thirty–sixth meeting, 16–20 June 2014 (Geneva, 2014). 321 For more details on the demand for tramadol, see the chapter 320 WHO, Expert Committee on Drug Dependence, “Annex 1: extract “Demand for opioids” in the present booklet. from the report of the forty-first Expert Committee on Drug Depend- 322 UNODC, responses to the annual report questionnaire. ence – cannabis and cannabis-related substances” (January 2019). 323 Conference room paper entitled “Country report: Benin” (UNODC/ 103 Fig. 79 Global quantities of tramadol seized, by region, 2010–2019

Annual quantities seized, 2010–2019 Average quantities seized over 2015–2019

125 Other 0.001% 100 Europe 75 2% Asia 50 3% West and Central Africa Ton equivalentsTon North 25 88% Africa 0 7% 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 West and Central Africa North Africa Near and Middle East/South-West Asia

WORLD DRUG REPORT 2021 REPORT DRUG WORLD South Asia

Other Asia Europe Other

Source: UNODC, responses to the annual report questionnaire.

most of the tramadol imported into Benin in recent years Trafficking in tramadol also continued in Africa in 2020, originated in India and was used for re-export to other although there may have been some changes regarding countries in West Africa and for domestic use.324 In three its country of origin and the routes used. For example, in tramadol seizure cases in February 2019 (273 kg, 330 August 2020, three containers loaded with a total of 15 kg and 105 kg) effected by authorities in Cotonou, the million tramadol tablets were intercepted by the seaport ship carrying the tramadol had departed from Singapore police in Lagos, Nigeria. The tablets had allegedly been (although it is unlikely that the tramadol originated there) produced in Pakistan and had transited Germany, before and the final destination of the container holding the reaching Nigeria as the final destination, according to tramadol was the Niger.325 In two subsequent tramadol the Nigerian authorities.327 Trafficking in pharmaceuti- seizures from containers at the seaport in Cotonou, made cal products, including tramadol, was also increasingly in February 2019 (3,750 kg and 8,904 kg), the ship had detected by West African joint airport interdiction task departed Singapore, with the origin identified as India forces in 2020, including in the case of a Nigerian national and the final destination as Nigeria.326 arriving in Abuja on a flight from Istanbul, Turkey.328

HONLAF/29/CRP.3), submitted to the Twenty-ninth Meeting of Heads of National Drug Law Enforcement Agencies, Africa. 327 Information made available to the National Drug Law Enforcement 324 United States, Department of Justice, Drug Enforcement Administra- Agencies, Africa, at its meetings during the extraordinary sessions tion, 2019 National Drug Threat Assessment. of the subsidiary bodies of the Commission on Narcotic Drugs, held 325 UNODC, Drugs Monitoring Platform. online on 1 and 2 October. 104 326 Individual drug seizures reported to UNODC by Member States. 328 Regional Office of West and Central Africa. ANNEX 3

Table 4 Annual prevalence of the use of cannabis, opioids and opiates, by region and globally, 2019

Opioids Cannabis Opiates Drug use

(opiates and prescription opioids)

Region | or subregion Number (thousands) Prevalence (percentage) Number (thousands) Prevalence (percentage) Number (thousands) Prevalence (percentage) Best Best Best Best Best Best Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper Lower Upper estimate estimate estimate estimate estimate estimate ANNEX ANNEX

Africa 46,950 28,150 64,080 6.41 3.85 8.75 9,050 6,360 12,140 1.24 0.87 1.66 3,580 1,430 7,910 0.49 0.20 1.08

East Africa ------

North Africa 7,850 6,900 9,170 5.26 4.63 6.15 1,580 1,060 2,100 1.06 0.71 1.41 1,580 1,060 2,100 1.06 0.71 1.41

Southern Africa ------West and 26,790 14,610 30,360 9.40 5.12 10.65 ------520 140 980 0.18 0.05 0.34 Central Africa

Americas 59,130 57,510 62,220 8.77 8.53 9.23 12,580 11,310 13,730 1.86 1.68 2.04 2,550 1,850 3,270 0.38 0.27 0.49

Caribbean 970 500 2,650 3.41 1.77 9.35 ------

Central America 1,000 340 1,750 3.12 1.08 5.48 ------

North America 47,120 46,950 47,290 14.53 14.47 14.58 11,790 10,690 12,630 3.63 3.30 3.89 2,280 1,690 2,800 0.70 0.52 0.86

South America 10,050 9,720 10,530 3.47 3.35 3.63 600 540 680 0.21 0.19 0.23 220 130 310 0.08 0.05 0.11

Asia 61,460 24,340 95,170 2.01 0.80 3.11 35,750 15,250 47,850 1.17 0.50 1.56 21,540 9,170 29,550 0.70 0.30 0.97

Central Asia and 1,520 450 2,500 2.58 0.77 4.25 570 500 660 0.97 0.85 1.12 570 490 660 0.97 0.83 1.11 Transcaucasia East and 19,330 8,710 24,010 1.19 0.54 1.48 3,290 2,420 4,020 0.20 0.15 0.25 3,290 2,420 4,020 0.20 0.15 0.25 South-East Asia South-West Asia/ 10,780 7,740 12,830 3.34 2.40 3.98 10,310 8,480 12,840 3.19 2.63 3.98 5,690 4,090 8,050 1.76 1.27 2.49 Near and Middle East South Asia 29,830 7,440 55,830 2.82 0.70 5.27 21,590 3,850 30,340 2.04 0.36 2.86 11,990 2,170 16,830 1.13 0.21 1.59

Europe 29,610 28,260 31,590 5.45 5.20 5.82 3,610 3,430 3,800 0.66 0.63 0.70 3,080 2,900 3,270 0.57 0.53 0.60

Eastern and South-Eastern 4,630 3,350 6,540 2.07 1.49 2.92 1,730 1,640 1,810 0.77 0.73 0.81 1,490 1,410 1,570 0.67 0.63 0.70 Europe Western and 24,980 24,910 25,050 7.83 7.81 7.85 1,880 1,790 1,990 0.59 0.56 0.62 1,590 1,490 1,700 0.50 0.47 0.53 Central Europe

Oceania 3,220 3,170 3,340 12.00 11.78 12.42 660 580 740 2.47 2.17 2.76 30 20 30 0.11 0.08 0.12

Australia and 2,360 2,360 2,360 12.14 12.14 12.14 ------New Zealand Melanesia ------

Micronesia ------

Polynesia ------

GLOBAL ESTIMATE 200,380 141,430 256,400 3.98 2.81 5.09 61,650 36,940 78,260 1.22 0.73 1.55 30,780 15,370 44,040 0.61 0.31 0.87 105 Sources: UNODC estimates based on annual report questionnaire data and other official sources. Note: Prevalence of people who use drugs is the percentage of the population aged 15–64 years. T able 5 Illicit cultivation of opium poppy, 2009–2020 (hectares)

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

SOUTH-WEST ASIA Afghanistan 123,000 123,000 131,000 154,000 209,000 224,000 183,000 201,000 328,000 263,000 163,000 224,000 (best estimate) lower bound a 102,000 104,000 109,000 125,000 173,000 196,000 163,000 182,000 301,000 242,000 149,000 202000 upper bound a 137,000 145,000 155,000 189,000 238,000 247,000 202,000 221,000 355,000 283,000 178,000 246000 SOUTH-EAST ASIA Lao People’s Democratic Republic 1,900 3,000 4,100 6,800 3,900 6,200 5,700 5,395 5,327 4,925 4,624 .. (best estimate) b, g lower bound a 1,100 1,900 2,500 3,100 1,900 3,500 3,900 upper bound a 2,700 4,000 6,000 11,500 5,800 9,000 7,600 Myanmar 31,700 38,100 43,600 51,000 57,800 57,600 55,500 .. 41,000 37,300 33,100 29,500 (best estimate) b, c WORLD DRUG REPORT 2021 REPORT DRUG WORLD lower bound a 20,500 17,300 29,700 38,249 45,710 41,400 42,800 30,200 29,700 25,800 21,000 upper bound a 42,800 58,100 59,600 64,357 69,918 87,300 69,600 51,900 47,200 42,800 50,400 SOUTH AND CENTRAL AMERICA Colombia 356 341 338 313 298 387 595 462 282 663 .. .. (best estimate) h Mexico 19,500 14,000 12,000 10,500 11,000 17,000 26,100 25,200 30,600 28,000 21,500 .. (best estimate) d, e, f lower bound a 21,800 20,400 22,800 21,200 15,500 upper bound a 30,400 30,000 38,400 34,800 27,500 OTHER Other countries i 9,479 12,221 16,390 12,282 13,293 11,585 8,549 54,641 8,792 11,815 14,656 40,855 TOTAL (best estimate) 185,935 190,662 207,428 234,895 295,291 316,772 279,444 286,698 414,001 345,703 236,880 294,355 lower bound 152,935 149,762 169,928 189,444 245,201 269,872 240,644 257,996 368,401 310,021 211,619 259,894 upper bound 211,835 233,662 249,328 287,952 338,309 372,272 318,744 333,396 459,701 382,121 247,587 323,187 TOTAL 185,930 190,660 207,430 234,900 295,290 316,770 279,440 286,700 414,000 345,700 236,880 294,350 (best estimate, rounded)

Sources: Afghanistan: Until 2018, Afghanistan Opium Surveys were conducted by the Ministry of Counter-Narcotics (MCN) of Afghanistan and the United Nations Office on Drugs and Crime (UNODC). Data for 2019-2020 was obtained from the UNODC Illicit Crop Monitoring Programme. Lao People’s Democratic Republic: Up till 2015, national illicit crop monitoring system supported by the United Nations Office on Drugs and Crime (UNODC). Data from 2016 onwards from Lao National Commission for Drug Control and Supervision. Myanmar: national illicit crop monitoring system supported by the United Nations Office on Drugs and Crime (UNODC). Colombia: Government of Colombia. Mexico: up to 2014, estimates derived from surveys by the Government of the United States of America (international narcotics control strategy reports); for 2015 onwards, joint Mexico/ UNODC project entitled “Monitoring of the illicit cultivation on Mexican territory”. Note: Two dots indicate that data were unavailable. Information on estimation methodologies and definitions can be found in the online methodology section of the World Drug Report 2021.

a) Bound of the statistically derived confidence interval. No. E.16.XI.7), have been revised owing to a statistical adjustment processed by UNODC. The 2015 b) May include areas that were eradicated after the date of the area survey. figures refer to the period July 2014–June 2015 and are not comparable with subsequent years, due to the updates in the methodology implemented from the 2015–2016 period onwards. c) In 2020, the opium poppy cultivation survey covered Shan and Kachin States. 46 sample locations were available in Shan and Kachin States (compared to 84 locations in 2019), which increased f) The figures for 2016, 2017, 2018 and 2019 are based on the estimation periods July 2015–June 2016, uncertainty around area and production estimates. Estimates for 2014, 2015, 2018 included area July 2016–June 2017 and July 2017–June 2018, July 2018–June 2019 respectively. estimates for Kayah and Chin states. In the absence of information on Kayah and Chin, the 2019, 2020 g) Data from 2016 onwards are not comparable to prior years. national area estimate uses latest available cultivation estimates (2018) for Chin and Kayah states. h) Data for 2018 from U.S. State Department, International Narcotics Control Strategy Report 2020. National estimates for 2014, 2015, 2018, 2019, 2020 are therefore not directly comparable with other years. i) Includes other countries with evidence of cultivation or production of opium poppy (average of less than 10 tons of opium per year since 2015) and estimates for countries with indirect evidence of illicit d) Up to 2014, the estimates for Mexico are sourced from the Department of State of the United States. cultivation (eradication of opium poppy) but no direct measurement. The Government of Mexico does not validate the estimates provided by the United States as they are not In addition, for 2016, 2018 and 2019 best estimates for countries for which data are not available part of its official figures and it does not have information on the methodology used to calculate them. (Myanmar for 2016, Colombia for 2019 and 2020, Lao People’s Democratic Republic 2020 and Mexico 106 e) The figures for 2015, as published in the World Drug Report 2016 (United Nations publication, Sales 2020) are included in this category. Table 6 Potential production of oven–dry opium, 2009–2020 (tons) 3 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

SOUTH-WEST ASIA Afghanistan 4,000 3,600 5,800 3,700 5,500 6,400 3,300 4,800 9,000 6,400 6,400 6,300 (best estimate) j lower bound a 3,000 4,800 2,800 4,500 5,100 2,700 4,000 8,000 5,600 5,600 5,400 Opium

a

upper bound 4,200 6,800 4,200 6,500 7,800 3,900 5,600 10,000 7,200 7,100 7,200 | SOUTH-EAST ASIA Lao People’s Democratic b, f 11 18 25 41 23 92 .. 48 48 44 41 ..

Republic (best estimate) ANNEX lower bound g 7 11 15 18 11 51 84 upper bound g 16 24 36 69 35 133 176 Myanmar (best estimate) b, h 330 580 610 690 870 670 647h .. 550 520 508 405 lower bound 213 350 420 520 630 481 500 395 410 380 289 upper bound 445 820 830 870 1,100 916 820 706 664 672 685 SOUTH AND CENTRAL AMERICA Colombia (best estimate) k 9 8 8 8 11 12 17 13 7 18 .. .. Mexico (best estimate) c, e, i 425 300 250 220 225 360 419 404 492 450 440 .. lower bound a 265 251 288 267 286 upper bound a 572 557 695 633 595 OTHER Other countries 178 224 290 172 182 201 147 711 143 168 227 708 (best estimate) d TOTAL (best estimate) 4,953 4,730 6,983 4,831 6,810 7,735 4,659 5,976 10,239 7,600 7,616 7,413 lower bound (published) 3,894 5,783 3,738 5,558 6,205 3,713 4,927 8,881 6,507 6,670 6,467 upper bound 5,576 8,214 5,539 8,052 9,423 5,632 7,153 11,599 8,727 8,462 8,259 TOTAL 4,950 4,730 6,980 4,830 6,810 7,740 4,660 5,980 10,240 7,600 7,620 7,410 best estimate (rounded)

Sources: Afghanistan: Until 2018, Afghanistan Opium Surveys were conducted by the Ministry of Counter-Narcotics (MCN) of Afghanistan and the United Nations Office on Drugs and Crime (UNODC). Data for 2019 was obtained from the UNODC Illicit Crop Monitoring Programme. Lao People’s Democratic Republic and Myanmar: national illicit crop monitoring system supported by the United Nations Office on Drugs and Crime (UNODC). Colombia: National illicit crop monitoring system supported by UNODC. Since 2008, production was calculated based on updated regional yield figures and conversion ratios from the Department of State and the Drug Enforcement Administration of the United States of America. Mexico: Up till 2014, estimates derived from surveys by the United States Government; from 2015 onwards national illicit crop monitoring system supported by UNODC. Note: Two dots indicate that data were unavailable. Information on estimation methodologies and definitions can be found in the online methodology section of the World Drug Report 2021. a) Bound of the statistically derived confidence interval. g) Bound of the statistically derived confidence interval, with the exception of 2015. The figures for 2015 b) Based on cultivation figures which may include areas eradicated after the date of the area survey. represent independently derived upper and lower estimates; the midpoint was used for the calculation of the global total. c) Up to 2014, the estimates are sourced from the Department of State of the United States. The Government of Mexico does not validate the estimates provided by the United States as they are not part h) Estimates for 2014, 2015, 2018 include estimates for Kayah and Chin states. In the absence of of its official figures and it does not have information on the methodology used to calculate them. information on Kayah and Chin, the 2019 national potential production estimate uses latest available (2018) cultivation estimates for Kayah and Chin states and the 2019 weighted national average yield d) Includes other countries with evidence of cultivation or production of opium poppy (average of less (15.4 kg/ha). National estimates for 2014, 2015, 2018 and 2019 are therefore not directly comparable than 10 tons of opium per year since 2015) and estimates for countries with indirect evidence of illicit with other years. cultivation (eradication of opium poppy) but no direct measurement. i) The figures for 2015, 2016, 2017, 2018, and 2019 are based on the estimation periods July 2014–June In addition, for 2016, 2018 and 2019 best estimates for countries for which data are not available 2015, July 2015–June 2016, July 2016–June 2017, July 2017–June 2018, and July 2018–June 2019 (Myanmar for 2016, Colombia for 2019 and 2020 and Lao People’s Democratic Republic 2020, Mexico respectively. 2020) are included in this category. j) Data on the potential opium production for 2019 and 2020 was obtained brom the UNODC Illicit e) The figures from 2015 on have been updated with newly available data. The joint Mexico/UNODC Crop Monitoring Programme. The same methodology was used as in previous years for yield project “Monitoring of the illicit cultivation on Mexican territory” collected yield data for the first time in measurement and estimation of potential opium production. The results for the year 2019 were not the 2017/2018 period. The production figures presented are based on: (1) annual estimates of area under validated by the Government of Afghanistan and are not recognized by the Government as its official cultivation, established by the joint project of the Government of Mexico and UNODC; (2) yield data estimate. collected in an initial survey in the 2017/2018 period. UNODC and Mexico are jointly working on continuously expanding the scope and quality of yield data collected. For methodological reasons, the k) Production estimates for 2018 based on cultivation estimates by the U.S. State Department figures shown for 2015-2018 are not comparable with the figures over the period 1998-2014. International Narcotics Control Strategy Report 2020 and average yields reported for the years 2015–2017. 107 f) Production estimates for the period 2016–2019 are based on cultivation estimates for the period 2016–2019 and average yields per ha reported over the 2012–2014 period. Table 7 Global manufacture of heroin from global illicit opium production, 2009–2020 (tons)

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Total potential 4,953 4,730 6,983 4,831 6,810 7,735 4,659 5,976 10,270 7,618 7,616 7,413 opium production

Potential opium not 1,680 1,728 3,400 1,850 2,600 2,450 1,360 2,510 1,100–1,400 1,225–1,525 1,180–1,480 1,177–1,477 processed into heroin

Potential opium 3,273 3,002 3,583 2,981 4,210 5,285 3,299 3,466 8,870–9,170 6,093–6,393 6,136–6,436 5,936–6,236 processed into heroin

Total potential 427 383 467 377 555 544 319 368 677–1,027 468–718 474–724 454–694 heroin manufacture

Notes: The calculation shows the potential amount of heroin that could have been manufactured out of the opium produced in a given year; it does not take into account changes in opium inventories, which may add to or reduce the amount of heroin entering the market in that year. Afghanistan and Myanmar are the only countries for which the proportion of potential opium production not converted into heroin within

WORLD DRUG REPORT 2021 REPORT DRUG WORLD the country is estimated. For Myanmar, these estimates were available only for 2018, 2019 and 2020. For all other countries, for the purposes of this table, it is assumed that all opium produced is converted into heroin. The amount of heroin produced from Afghan opium is calculated using two parameters that may change: (a) the amounts of opium consumed as raw opium in the region; and (b) the conversion ratio into heroin. The first parameter’s estimate is based on consumption data in Afghanistan and neighbouring countries. For the second parameter, from 2005 to 2013, a conversion ratio of opium to morphine/heroin of 7:1 was used, based on interviews conducted with /heroin “cooks”, on an actual heroin production exercise conducted by two (illiterate) Afghan heroin “cooks”, documented by the German Bundeskrimi- nalamt in Afghanistan in 2003 (published in Bulletin on Narcotics, vol. LVII, Nos. 1 and 2, 2005, pp. 11–31), and United Nations Office on Drugs and Crime (UNODC) studies on the morphine content of Afghan opium (12.3 per cent over the period 2010–2012, down from 15 per cent over the period 2000–2003). Starting from 2014, a different approach to the conversion was adopted, reflecting updated information on morphine content and a different method for taking purity into account. The revised approach uses a ratio of 18.5 (range: 17.5–19.6) kg of opium for 1 kg of 100 per cent pure heroin base (see Afghanistan Opium Survey 2014, UNODC, November 2014). In addition, the conversion into export-quality heroin assumes purity to be between 50 and 70 per cent. For more details, see “Afghanistan Opium Survey 2017 – Challenges to sustainable development, peace and security” (UNODC, May 2018). The amount of heroin produced in Myanmar in 2018 , 2019 and 2020 was calculated by subtracting the estimated unprocessed opium for consumption from the total opium production and using a conversion factor of 10:1. The unprocessed opium in Myanmar was based on the total unprocessed opium in East Asia and the relative cultivation levels of Lao PDR and Myanmar (see Transnational Organized Crime in East Asia and the Pacific – A Threat Assessment, UNODC, 2013 and Transnational Organized Crime in Southeast Asia: Evolution, Growth and Impact 2019, UNODC, 2019). For further information, please refer to the Methodology chapter (section 4.3) of the Myanmar Opium Survey 2018 (UNODC, January 2019) and the Myanmar Opium Survey 2019 (UNODC, February 2020). For countries other than Afghanistan, a “traditional” conversion ratio of opium to heroin of 10:1 is used. The ratios will be adjusted when improved information becomes available. Figures in italics are preliminary and may be revised when updated information becomes available.

108 Table 8 Cannabis cultivation, production and eradication, latest year available from the period 2013–2019 3 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2012 Afghanistan resin outdoors 10,000 1,400 2016 Albania herb outdoors 2,536,288 5,205 2017 Albania herb Indoors 7,766 2017 Albania herb outdoors 66,927 500 Cannabis

2017 Albania herb outdoors 33,177 379 | 2018 Albania herb Indoors 2,716 2014 Algeria resin outdoors 2,522 a

2016 Armenia herb outdoors 0.50 0.50 0.00 757 20 ANNEX 2017 Armenia herb outdoors 0.50 a 0.50 0.00 2,547 21 2018 Armenia herb Indoors 1,025 36 2016 Australia herb indoors 31,266 408 2016 Australia herb outdoors 22,257 1,021 2017 Australia herb indoors 78,310 433 2017 Australia herb outdoors 1.00 a 1.00 0.00 31,431 948 2018 Australia herb indoors 38,492 542 2018 Australia herb outdoors 0.80 a 0.80 0.00 19,981 1,120 2015 Austria herb outdoors 3.00 a 3.00 0.00 2013 Azerbaijan herb outdoors 23.95 a 23.95 0.00 263.96 8,469 151 2014 Azerbaijan herb outdoors 17.50 a 17.50 0.00 14,889 195 2017 Azerbaijan herb outdoors 0.25 a 0.25 336,791 2015 Bahamas herb outdoors 17,270 2012 Bangladesh herb outdoors 39,848 2013 Bangladesh herb outdoors 35,012 2014 Bangladesh herb outdoors 35,988 2015 Bangladesh herb outdoors 39,967 2016 Bangladesh herb outdoors 47,104 2017 Bangladesh herb outdoors 69,989 2016 Belarus herb indoors 28 2016 Belarus herb oudoors 123.80 1,945 2017 Belarus herb indoors 32 2017 Belarus herb oudoors 125.90 2,283 2018 Belarus herb indoors 42 2018 Belarus herb oudoors 106.30 2,469 2015 Belgium herb indoors 345,518 1,164 2015 Belgium herb outdoors 4,885 93 2017 Belgium herb indoors 415,728 1,175 2017 Belgium herb outdoors 848 59 2018 Belgium herb indoors 421,326 944 2018 Belgium herb outdoors 935 62 2015 Belize herb outdoors 50,897 2017 Bhutan herb outdoors 1.00 a 1.00 0.00 100,000 12 2016 Bolivia (Plurinational State of) herb outdoors 14.60 35 2017 Bolivia (Plurinational State of) herb outdoors 14.00 52 2018 Bolivia (Plurinational State of) herb outdoors 13.36 52 2016 Bosnia and Herzegovina herb indoors 39.00 2016 Bosnia and Herzegovina herb outdoors 1,680.00 2017 Bosnia and Herzegovina herb indoors 1 1 2017 Bosnia and Herzegovina herb outdoors 0.02 a 0.02 0.00 539 53 2018 Bosnia and Herzegovina herb indoors 0.02 a 0.02 0.00 6 109 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2018 Bosnia and Herzegovina herb outdoors 0.02 a 0.02 0.00 1,580 12 2014 Brazil herb outdoors 44.01 1,364,316 2017 Brazil herb outdoors 117.51 1,910,451 604 2018 Brazil herb outdoors 68.31 968,145 2015 Bulgaria herb indoors 323 2015 Bulgaria herb outdoors 37.77 9,488 2017 Central African Republic herb outdoors 130.00 60.00 55 10.00 250,000 22 2016 Chile herb indoors 26,988 2,740 2016 Chile herb outdoors 58,950 264 2017 Chile herb indoors 50,414 2,408 2017 Chile herb outdoors 194,694 202 2018 Chile herb indoors 66,007 2,357 2018 Chile herb outdoors 183,185 318 2016 China herb outdoors 9.80 1,390,000

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2018 China herb outdoors 710 2016 Colombia herb outdoors 135.00 2017 Colombia herb outdoors 173.71 2018 Colombia herb outdoors 59.66 2016 Costa Rica herb indoors 678.00 5 2016 Costa Rica herb outdoors 17.59 2,122,244 201 2017 Costa Rica herb indoors 2 2017 Costa Rica herb outdoors 14.30 215 2018 Costa Rica herb indoors 4 2018 Costa Rica herb outdoors 11.41 11.41 1,346,273 208 2016 Côte d’Ivoire herb outdoors 5 2017 Côte d’Ivoire herb outdoors 0.25 1 2018 Côte d’Ivoire herb outdoors 104 1 2016 Czechia herb indoors 53,549 229 2016 Czechia herb outdoors 4,111 2017 Czechia herb indoors 50,925 305 2017 Czechia herb outdoors 3,467 2018 Czechia herb outdoors 6,581 2015 Denmark herb indoors/outdoors 14,560 97 2016 Denmark herb indoors/outdoors 13,217 105 2017 Denmark herb indoors/outdoors 34,801 65 2014 Dominican Republic herb outdoors 6.00 a 6.00 0.00 0.21 111 8 2016 Ecuador herb outdoors 224 34 2017 Ecuador herb outdoors 397 10 2018 Ecuador herb indoors 127 30 2018 Ecuador herb outdoors 13,891 4 2015 Egypt herb/resin outdoors 140.00 2017 Egypt herb/resin outdoors 126.00 2018 Eswatini herb outdoors 1,500.00 1,069.50 430.50 3,000,000 210 2017 Georgia herb indoors 0.01 186 91 2017 Georgia herb outdoors 0.02 a 0.02 0.00 93 19 2016 El Salvador herb outdoors 1.00 227 25 2014 France herb outdoors 158,592 837 2018 France herb outdoors 138,561 2017 Georgia herb indoors 0.01 186 91 2017 Georgia herb outdoors 0.02 0.02 0.00 93 19 110 2018 Georgia herb indoors 0.05 927 443 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated 3 indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2018 Georgia herb outdoors 0.10 0.10 0.00 406 98 2015 Germany herb indoors 135,925 786 2015 Germany herb outdoors 9,136 127 2017 Germany herb indoors 85,226 573 2017 Germany herb outdoors 95 2016 Greece herb indoors 16,554 Cannabis

2016 Greece herb oudoors 39,151 | 2017 Greece herb indoors 19,498 2017 Greece herb oudoors 27,409

2018 Greece herb indoors 6,913 ANNEX 2018 Greece herb oudoors 43,684 2016 Guatemala herb outdoors 9.00 3,138,298 427 2017 Guatemala herb outdoors 3.50 a 3.81 1.61 6,033,345 150 2018 Guatemala herb outdoors 129.00 a 129.00 0.00 5,189,422 368 2015 Guyana herb outdoors 20.00 9.40 10.60 1,000.00 419,700 19 2016 Honduras herb indoors 7 2 2016 Honduras herb oudoors 24,253 19 2017 Honduras herb oudoors 59.58 a 59.59 0.00 2018 Honduras herb oudoors 720,426 67 2016 China, Hong Kong SAR herb indoors 329 1 2016 Hungary herb indoors 5,000 3 2016 Hungary herb outdoors 2,000 20 2013 Iceland herb indoors 6,652 323 2016 India herb outdoors 3,414.74 2017 India herb outdoors 3,445.90 6,687,376 2018 India herb outdoors 3,430.12 2016 Indonesia herb outdoors 482.00 a 482.00 0.00 2017 Indonesia herb outdoors 89.00 a 89.00 0.00 738,020 14 2018 Indonesia herb outdoors 76.23 a 76.23 0.00 1,455,390 13 2018 Iran (Islamic Republic of) herb indoors 0.04 2016 Ireland herb indoors 7,273 2017 Ireland herb indoors 9,046 50 2018 Ireland herb indoors 7,186 2014 Italy herb indoors 51,534 639 2014 Italy herb outdoors 70,125 1,134 2017 Italy herb indoors 56,125 1,161 2017 Italy herb outdoors 209,510 401 2012 Jamaica herb outdoors 456 382 2016 Kazakhstan herb outdoors 18.00 a 18.00 0.00 170,000 202 2017 Kazakhstan herb outdoors 12.30 a 12.30 0.00 930,774 91 2016 Kenya herb outdoors 12.00 8,747 46 2017 Kenya herb outdoors 0.10 4,662 2018 Kenya herb outdoors 0.10 517 2015 Kyrgyzstan herb outdoors 5,014.00 5,014.00 2018 Kyrgyzstan herb outdoors 1,276.37 457.69 818.68 49,942 12.00 2016 Latvia herb indoors 557 35 2016 Latvia herb outdoors 78 6 2017 Latvia herb indoors 798 34 2017 Latvia herb outdoors 66 15 2018 Latvia herb indoors 152 17 2018 Latvia herb outdoors 1,152 34 111 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2015 Lebanon herb outdoors 3,500.00 3,500.00 2017 Lebanon Kif outdoors 40,772.00 2018 Lebanon herb outdoors 4,205.70 4,205.70 2016 Lithuania herb indoors 4 2017 Lithuania herb indoors 8 2017 Lithuania herb outdoors 7 2018 Lithuania herb indoors 3 2015 Madagascar herb outdoors 11.00 21,325 2017 Madagascar herb outdoors 9.00 57,708 2013 Malta herb indoors 27 2016 Mexico herb outdoors 5,478.42 6,574.1 38,432 2017 Mexico herb outdoors 4,193.34 5,032.0 34,523 2018 Mexico herb outdoors 2,263.71 2,716.47 28,873 2013 Mongolia herb outdoors 15,000.00 4,000.00 11,000.00 4,000 4,000

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2018 Mongolia herb outdoors 15,000.00 173.00 14,827.00 33 2016 Morocco herb outdoors 35,652.83 2016 Morocco plant outdoors 47,000.00 395.00 46,605.00 2016 Morocco resin outdoors 713.00 2017 Morocco herb outdoors 35,702.90 2017 Morocco plant outdoors 47,500.00 523.00 46,977.00 2017 Morocco resin outdoors 714.06 2018 Morocco herb outdoors 23,699.80 2018 Morocco plant outdoors 47,500.00 47,500.00 2018 Morocco resin outdoors 423.58 2014 Myanmar herb outdoors 15.00 10.00 5.00 3 2018 Nepal herb outdoors 235.87 235.87 0.00 5,000.00 2,358,700 335 2016 Netherlands herb indoors 994,068 5,856 2017 Netherlands herb indoors 883,163 5,538 2018 Netherlands herb indoors 516,418 3,482 2018 Netherlands herb outdoors 431 2016 New Zealand herb indoors 18,903 607 2016 New Zealand herb outdoors 104,725 2017 New Zealand herb indoors 19,992 2017 New Zealand herb outdoors 19,559 2018 New Zealand herb indoors 19,313 2018 New Zealand herb outdoors 22,660 2014 Nicaragua herb outdoors 0.30 1,507.00 3,014 30 2016 Nicaragua herb outdoors 275,000 2017 Nicaragua herb outdoors 994,787 2016 Nigeria herb outdoors 718.78 65 2017 Nigeria herb outdoors 317.12 2018 Nigeria herb outdoors 3,660.64 2015 Norway herb indoors 0.04 4,000 30 2017 North Macedonia herb indoors 168 2017 North Macedonia herb outdoors 220 2018 North Macedonia herb outdoors 2.51 4.04 2,264 4,527 2016 Oman herb outdoors 0.50 a 0.50 0.00 5 3 2013 Panama herb indoors 0.50 a 0.50 0.00 37 2 2013 Panama herb outdoors 10.50 a 10.50 0.00 78,633 2 2016 Paraguay herb outdoors 1,298.50 112 2016 Paraguay plant outdoors 1,298.50 a 1,298.50 0.00 5,656,266 4 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated 3 indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2016 Paraguay resin outdoors 1.15 2017 Paraguay plant outdoors 1,462.00 36,550,000 2016 Peru herb outdoors 87.83 1,429,749 2017 Peru herb outdoors 61.30 4,671,387 47 2018 Peru herb outdoors 91.80 1,716,751 46 2016 Philippines herb outdoors 8.67 24,635,153 337 Cannabis

2017 Philippines herb outdoors 4.82 221,035 27 | 2018 Philippines herb outdoors 12.39 869,682 186 2016 Poland herb indoors 146,755 1,403

2016 Poland herb indoors/outdoors 4,585 219 ANNEX 2017 Poland herb indoors 448 10 2017 Poland herb indoors/outdoors 54 2018 Poland herb indoors/outdoors 118,382 1,274 2017 herb indoors/outdoors 22,910 158 2018 Portugal herb indoors/outdoors 8,706 139 2013 Republic of Korea herb outdoors 8,072 2014 Republic of Moldova herb outdoors 100.00 59.00 41.00 10,000.00 200,548 2017 Republic of Moldova herb outdoors 0.15 2.57 257,236 2018 Republic of Moldova herb outdoors 0.71 86,926 61 2014 Republic of Moldova herb indoors 41.00 2016 Romania herb indoors 1,433 41 2016 Romania herb outdoors 6.99 42 2017 Romania herb indoors 1,875 46 2017 Romania herb outdoors 1.90 4,905 32 2018 Romania herb indoors 3,903 39 2018 Romania herb outdoors 0.11 1,882 98 2016 Russian Federation herb indoors 0.66 788 2016 Russian Federation herb outdoors 7.61 a 7.61 0.00 68.64 1,143 2016 Albania herb outdoors 2,536,288 5,205 2017 Albania herb Indoors 7,766 2017 Albania herb outdoors 66,927 500 2017 Albania herb outdoors 33,177 379 2018 Albania herb Indoors 2,716 2014 Algeria resin outdoors 2,522 2016 Armenia herb outdoors 0.50 a 0.50 0.00 757 20 2017 Armenia herb outdoors 0.50 a 0.50 0.00 2,547 21 2018 Armenia herb Indoors 1,025 36 2016 Australia herb indoors 31,266 408 2016 Australia herb outdoors 22,257 1,021 2017 Australia herb indoors 78,310 433 2017 Australia herb outdoors 1.00 a 1.00 0.00 31,431 948 2018 Australia herb indoors 38,492 542 2018 Australia herb outdoors 0.80 a 0.80 0.00 19,981 1,120 2019 Australia herb indoors 1.72 50,837 86 2019 Australia herb outdoors 0.04 a 0.04 0.00 4,755 1 2015 Austria herb outdoors 3.00 a 3.00 0.00 2013 Azerbaijan herb outdoors 23.95 a 23.95 0.00 263.96 8,469 151 2014 Azerbaijan herb outdoors 17.50 a 17.50 0.00 14,889 195 2017 Azerbaijan herb outdoors 0.25 a 0.25 336,791 2015 Bahamas herb outdoors 17,270 2013 Bangladesh herb outdoors 35,012 113 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2014 Bangladesh herb outdoors 35,988 2015 Bangladesh herb outdoors 39,967 2016 Bangladesh herb outdoors 47,104 2017 Bangladesh herb outdoors 69,989 2016 Belarus herb indoors 28 2016 Belarus herb oudoors 123.80 1,945 2017 Belarus herb indoors 32 2017 Belarus herb oudoors 125.90 2,283 2018 Belarus herb indoors 42 2018 Belarus herb oudoors 106.30 2,469 2019 Belarus herb indoors 28 2019 Belarus herb oudoors 117.60 2,182 2015 Belgium herb indoors 345,518 1,164 2015 Belgium herb outdoors 4,885 93

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2016 Belgium herb indoors 327,216 1,012 2016 Belgium herb outdoors 1,395 34 2017 Belgium herb indoors 415,728 1,175 2017 Belgium herb outdoors 848 59 2018 Belgium herb indoors 421,326 944 2018 Belgium herb outdoors 935 62 2015 Belize herb outdoors 50,897 2017 Bhutan herb outdoors 1.00 a 1.00 0.00 100,000 12 2016 Bolivia (Plurinational State of) herb outdoors 14.60 35 2017 Bolivia (Plurinational State of) herb outdoors 14.00 52 2018 Bolivia (Plurinational State of) herb outdoors 13.36 52 2019 Bolivia (Plurinational State of) herb outdoors 22.50 50 2016 Bosnia and Herzegovina herb indoors 39.00 2016 Bosnia and Herzegovina herb outdoors 1,680.00 2017 Bosnia and Herzegovina herb indoors 1 1 2017 Bosnia and Herzegovina herb outdoors 0.02 a 0.02 0.00 539 53 2018 Bosnia and Herzegovina herb indoors 0.02 a 0.02 0.00 6 2018 Bosnia and Herzegovina herb outdoors 0.02 a 0.02 0.00 1,580 12 2019 Bosnia and Herzegovina herb outdoors 30.00 a 2014 Brazil herb outdoors 44.01 1,364,316 2017 Brazil herb outdoors 117.51 1,910,451 604 2018 Brazil herb outdoors 68.31 968,145 2019 Brazil herb outdoors 74.53 475.70 1,585,759 651 2015 Bulgaria herb indoors 323 2015 Bulgaria herb outdoors 37.77 9,488 2017 Central African Republic herb outdoors 130.00 60.00 55 10.00 250,000 22 2016 Chile herb indoors 26,988 2,740 2016 Chile herb outdoors 58,950 264 2017 Chile herb indoors 50,414 2,408 2017 Chile herb outdoors 194,694 202 2018 Chile herb indoors 66,007 2,357 2018 Chile herb outdoors 183,185 318 2019 Chile herb indoors 31,711 1,856 2019 Chile herb outdoors 199,523 212 2016 China herb outdoors 9.80 1,390,000 2018 China herb outdoors 710 114 2016 China, Hong Kong SAR herb indoors 329 1 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated 3 indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2019 China, Hong Kong SAR herb indoors 1,693 2016 Colombia herb outdoors 135.00 2017 Colombia herb outdoors 173.71 2018 Colombia herb outdoors 59.66 2019 Colombia herb outdoors 39.34 2016 Costa Rica herb indoors 678.00 5 Cannabis

2016 Costa Rica herb outdoors 17.59 2,122,244 201 | 2017 Costa Rica herb indoors 2 2017 Costa Rica herb outdoors 14.30 215

2018 Costa Rica herb indoors 4 ANNEX 2018 Costa Rica herb outdoors 11.41 11.41 1,346,273 208 2019 Costa Rica herb indoors 2 2019 Costa Rica herb outdoors 11.56 11.56 1,419,495 224 2016 Côte d’Ivoire herb outdoors 5 2017 Côte d’Ivoire herb outdoors 0.25 1 2018 Côte d’Ivoire herb outdoors 104 1 2019 Côte d’Ivoire herb outdoors 4,848 2016 Czechia herb indoors 53,549 229 2016 Czechia herb outdoors 4,111 2017 Czechia herb indoors 50,925 305 2017 Czechia herb outdoors 3,467 2018 Czechia herb outdoors 6,581 2019 Czechia herb indoors 26,925 258 2019 Czechia herb outdoors 5,526 2015 Denmark herb indoors/outdoors 14,560 97 2016 Denmark herb indoors/outdoors 13,217 105 2018 Denmark herb indoors/outdoors 14,171 99 2019 Denmark herb indoors/outdoors 14,338 79 2014 Dominican Republic herb outdoors 6.00 a 6.00 0.00 0.21 111 8 2017 Denmark herb indoors/outdoors 34,801 65 2016 Ecuador herb outdoors 224 34 2017 Ecuador herb outdoors 397 10 2018 Ecuador herb indoors 127 30 2018 Ecuador herb outdoors 13,891 4 2015 Egypt herb/resin outdoors 140.00 2017 Egypt herb/resin outdoors 126.00 2016 El Salvador herb outdoors 1.00 227 25 2019 Estonia herb indoors 979 27 2019 Estonia herb outdoors 66 2 2018 Eswatini herb outdoors 1,500.00 1,069.50 430.50 3,000,000 210 2018 France herb outdoors 138,561 2014 France herb outdoors 158,592 837 2017 Georgia herb indoors 0.01 186 91 2017 Georgia herb outdoors 0.02 a 0.02 0.00 93 19 2017 Georgia herb indoors 0.01 186 91 2017 Georgia herb outdoors 0.02 0.02 0.00 93 19 2018 Georgia herb indoors 0.05 927 443 2018 Georgia herb outdoors 0.10 0.10 0.00 406 98 2015 Germany herb indoors 135,925 786 2015 Germany herb outdoors 9,136 127 2016 Germany herb indoors 79,599 712 115 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2016 Germany herb outdoors 18,414 108 2017 Germany herb indoors 85,226 573 2017 Germany herb outdoors 95 2016 Greece herb indoors 16,554 2016 Greece herb oudoors 39,151 2017 Greece herb indoors 19,498 2017 Greece herb oudoors 27,409 2018 Greece herb indoors 6,913 2018 Greece herb oudoors 43,684 2016 Guatemala herb outdoors 9.00 3,138,298 427 2017 Guatemala herb outdoors 3.50 a 3.81 1.61 6,033,345 150 2018 Guatemala herb outdoors 129.00 a 129.00 0.00 5,189,422 368 2019 Guatemala herb outdoors 150.00 a 84.26 65.74 3,447,979 127 2015 Guyana herb outdoors 20.00 9.40 10.60 1,000.00 419,700 19

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2016 Honduras herb indoors 7 2 2016 Honduras herb oudoors 24,253 19 2017 Honduras herb oudoors 59.58 a 59.59 0.00 2018 Honduras herb oudoors 720,426 67 2019 Honduras herb oudoors 228,542 46 2016 Hungary herb indoors 5,000 3 2016 Hungary herb outdoors 2,000 20 2013 Iceland herb indoors 6,652 323 2016 India herb outdoors 3,414.74 2017 India herb outdoors 3,445.90 6,687,376 2018 India herb outdoors 3,430.12 2019 India herb outdoors 9,023.27 2016 Indonesia herb outdoors 482.00 a 482.00 0.00 2017 Indonesia herb outdoors 89.00 a 89.00 0.00 738,020 14 2018 Indonesia herb outdoors 76.23 a 76.23 0.00 1,455,390 13 2019 Indonesia herb outdoors 103.20 a 84.50 18.70 169.00 845,000 25 2018 Iran (Islamic Republic of) herb indoors 0.04 2016 Ireland herb indoors 7,273 2017 Ireland herb indoors 9,046 50 2018 Ireland herb indoors 7,186 2019 Ireland herb indoors 8,576 2014 Italy herb indoors 51,534 639 2014 Italy herb outdoors 70,125 1,134 2017 Italy herb indoors 56,125 1,161 2017 Italy herb outdoors 209,510 401 2019 Italy herb indoors 68,266 2019 Italy herb outdoors 155,275 2016 Kazakhstan herb outdoors 18.00 a 18.00 0.00 170,000 202 2017 Kazakhstan herb outdoors 12.30 a 12.30 0.00 930,774 91 2016 Kenya herb outdoors 12.00 8,747 46 2017 Kenya herb outdoors 0.10 4,662 2018 Kenya herb outdoors 0.10 517 2019 Kenya herb outdoors 0.25 a 0.25 0.00 130 1 2015 Kyrgyzstan herb outdoors 5,014.00 5,014.00 2018 Kyrgyzstan herb outdoors 1,276.37 457.69 818.68 49,942 12.00 2016 Latvia herb indoors 557 35 116 2016 Latvia herb outdoors 78 6 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated 3 indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2017 Latvia herb indoors 798 34 2017 Latvia herb outdoors 66 15 2018 Latvia herb indoors 152 17 2018 Latvia herb outdoors 1,152 34 2019 Latvia herb indoors 932 34 2019 Latvia herb outdoors 61 12 Cannabis

2015 Lebanon herb outdoors 3,500.00 3,500.00 | 2017 Lebanon Kif outdoors 40,772.00 2018 Lebanon herb outdoors 4,205.70 4,205.70

2016 Lithuania herb indoors 4 ANNEX 2017 Lithuania herb indoors 8 2017 Lithuania herb outdoors 7 2018 Lithuania herb indoors 3 2015 Madagascar herb outdoors 11.00 21,325 2017 Madagascar herb outdoors 9.00 57,708 2013 Malta herb indoors 27 2016 Mexico herb outdoors 5,478.42 6,574.1 38,432 2017 Mexico herb outdoors 4,193.34 5,032.0 34,523 2018 Mexico herb outdoors 2,263.71 2,726.47 28,873 2013 Mongolia herb outdoors 15,000.00 4,000.00 11,000.00 4,000 4,000 2018 Mongolia herb outdoors 15,000.00 173.00 14,827.00 33 2016 Morocco herb outdoors 35,652.83 2016 Morocco plant outdoors 47,000.00 395.00 46,605.00 2016 Morocco resin outdoors 713.00 2017 Morocco herb outdoors 35,702.90 2017 Morocco plant outdoors 47,500.00 523.00 46,977.00 2017 Morocco resin outdoors 714.06 2018 Morocco herb outdoors 23,699.80 2018 Morocco plant outdoors 47,500.00 47,500.00 2018 Morocco resin outdoors 423.58 2019 Morocco plant outdoors 21,048.71 135.50 20,913.21 2019 Morocco resin outdoors 596.03 2014 Myanmar herb outdoors 15.00 10.00 5.00 3 2018 Nepal herb outdoors 235.87 235.87 0.00 5,000.00 2,358,700 335 2016 Netherlands herb indoors 994,068 5,856 2017 Netherlands herb indoors 883,163 5,538 2018 Netherlands herb indoors 516,418 3,482 2018 Netherlands herb outdoors 431 2019 Netherlands herb indoors 556,802 3,285 2019 Netherlands herb outdoors 350 2016 New Zealand herb indoors 18,903 607 2016 New Zealand herb outdoors 104,725 2017 New Zealand herb indoors 19,992 2017 New Zealand herb outdoors 19,559 2018 New Zealand herb indoors 19,313 2018 New Zealand herb outdoors 22,660 2019 New Zealand herb indoors 18,052 2019 New Zealand herb outdoors 15,269 2014 Nicaragua herb outdoors 0.30 1,507.00 3,014 30 2016 Nicaragua herb outdoors 275,000 2017 Nicaragua herb outdoors 994,787 117 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2016 Nigeria herb outdoors 718.78 65 2017 Nigeria herb outdoors 317.12 2018 Nigeria herb outdoors 3,660.64 2017 North Macedonia herb indoors 168 2017 North Macedonia herb outdoors 220 2018 North Macedonia herb outdoors 2.51 0.00404 2,264 4,527 2015 Norway herb indoors 0.04 4,000 30 2016 Oman herb outdoors 0.50 a 0.50 0.00 5 3 2013 Panama herb indoors 0.50 a 0.50 0.00 37 2 2013 Panama herb outdoors 10.50 a 10.50 0.00 78,633 2 2016 Paraguay herb outdoors 1,298.50 2016 Paraguay plant outdoors 1,298.50 a 1,298.50 0.00 5,656,266 4 2016 Paraguay resin outdoors 1.15 2017 Paraguay plant outdoors 1,462.00 36,550,000

WORLD DRUG REPORT 2021 REPORT DRUG WORLD 2016 Peru herb outdoors 87.83 1,429,749 2017 Peru herb outdoors 61.30 4,671,387 47 2018 Peru herb outdoors 91.80 1,716,751 46 2016 Philippines herb outdoors 8.67 24,635,153 337 2017 Philippines herb outdoors 4.82 221,035 27 2018 Philippines herb outdoors 12.39 869,682 186 2019 Philippines herb outdoors 149.35 2,345,650 137 2016 Poland herb indoors 146,755 1,403 2016 Poland herb indoors/outdoors 4,585 219 2017 Poland herb indoors 448 10 2017 Poland herb indoors/outdoors 54 2018 Poland herb indoors/outdoors 118,382 1,274.00 2019 Poland herb indoors 2,840 2 2019 Poland herb indoors/outdoors 5,124 17 2017 Portugal herb indoors/outdoors 22,910 158 2018 Portugal herb indoors/outdoors 8,706 139 2019 Portugal herb indoors/outdoors 12,077 131 2013 Republic of Korea herb outdoors 8,072 2014 Republic of Moldova herb indoors 41.00 2014 Republic of Moldova herb outdoors 100.00 59.00 41.00 10,000.00 200,548 2017 Republic of Moldova herb outdoors 0.15 2.57 257,236 2018 Republic of Moldova herb outdoors 0.71 86,926 61 2019 Republic of Moldova herb outdoors 143,537 2016 Romania herb indoors 1,433 41 2016 Romania herb outdoors 6.99 42 2017 Romania herb indoors 1,875 46 2017 Romania herb outdoors 1.90 4,905 32 2018 Romania herb indoors 3,903 39 2018 Romania herb outdoors 0.11 1,882 98 2019 Romania herb indoors 0.49 2,096 39 2019 Romania herb outdoors 787 44 2016 Russian Federation herb indoors 0.66 788 2016 Russian Federation herb outdoors 7.61 a 7.61 0.00 68.64 1,143 2017 Russian Federation herb indoors 0.87 1,990 2017 Russian Federation herb outdoors 159.00 a 159.00 0.00 30.07 5,379 2018 Russian Federation herb indoors 1.87 118 2018 Russian Federation herb outdoors 9.34 a 7.47 1.87 16,212 Area Area Outdoors/ Harvestable Production Plants Sites Year Country / Territory Product cultivated eradicated 3 indoors area (ha) (tons) eradicated eradicated (ha) (ha) 2019 Russian Federation herb indoors 0.72 2,112 2019 Russian Federation herb outdoors 161.10 3,571 2015 Serbia herb outdoors 0.05 2013 Sierra Leone herb outdoors 190.00 190.00 190 3 2016 Slovakia herb indoors 385 2017 Slovakia herb outdoors 2.00 a 2.00 0.00 2,299 31 Cannabis

2019 Slovakia herb indoors 1,611 41 | 2014 Slovenia herb indoors 9,223 118 2014 Slovenia herb outdoors 1,844

2017 Slovenia herb indoors 10,259 78 ANNEX 2015 Spain herb indoors 244,772 108 2015 Spain herb outdoors 135,074 44 2014 Sudan herb outdoors 8.00 a 8.00 0.00 345.00 2017 Sudan herb outdoors 1,250.00 a 1,250.00 0.00 205.00 100 2018 Sudan herb outdoors 7,744.00 a 1,452.00 6,292.00 774,400.00 1,500,000 3 2014 Sweden herb indoors 10,000 56 2015 Sweden herb outdoors 182.00 2017 Sweden herb indoors 5,100 44 2018 Sweden herb indoors 1,642 2016 Switzerland herb indoors 11,386 83 2017 Switzerland herb indoors 71,750 2016 Thailand herb outdoors 1.00 a 1.00 0.00 7.50 1 2019 Thailand herb outdoors 1.50 a 1.50 0.00 45.00 4,790 53 2019 Togo herb outdoors 0.06 1 2015 Trinidad and Tobago herb outdoors 0.31 375,925 58 2016 Ukraine herb outdoors 91.00 a 91.00 0.00 2017 Ukraine herb outdoors 166.90 483,000 2019 Ukraine herb outdoors 47.00 1,800,000 2,135 2016 United States of America herb indoors 406,125 1,865 2016 United States of America herb outdoors 4,940,596 5,513 2017 United States of America herb indoors 303,654 1,399 2017 United States of America herb outdoors 3,078,418 4,062 2018 United States of America herb indoors 596,149 1,618 2018 United States of America herb outdoors 2,221,837 3,847 2019 United States of America herb indoors 770,472 1,437 2019 United States of America herb outdoors 3,232,722 3,850 2016 Uruguay herb indoors 661 2017 Uruguay herb indoors 1,926 2019 Uruguay herb indoors 1,654 2016 Uzbekistan herb outdoors 0.20 a 0.20 0.00 586 2017 Uzbekistan herb outdoors 0.20 a 0.20 0.00 618 2018 Uzbekistan herb indoors 0.13 a 0.13 0.00 519 2019 Uzbekistan herb outdoors 0.11 a 0.11 0.00 417 2018 Venezuela herb oudoors 13,891 4 2015 Viet Nam herb oudoors 1.00

Sources: United Nations Office on Drugs and Crime annual report questionnaire, government reports and and international narcotics control strategy reports of the United States of America. a) Estimate of total area under cannabis cultivation.

119

GLOSSARY 3

amphetamine-type stimulants — a group of substances opiates — a subset of opioids comprising the various prod- composed of synthetic stimulants controlled under the ucts derived from the opium poppy plant, including Convention on Psychotropic Substances of 1971, which opium, morphine and heroin. includes amphetamine, methamphetamine, meth- and the “ecstasy”-group substances (3,4-me- opioids — a generic term that refers both to opiates and GLOSSARY thylenedioxymethamphetamine (MDMA) and its their synthetic analogues (mainly prescription or pharma- analogues). ceutical opioids) and compounds synthesized in the body. amphetamines — a group of amphetamine-type stimulants problem drug users — people who engage in the high-risk that includes amphetamine and methamphetamine. consumption of drugs. For example, people who inject drugs, people who use drugs on a daily basis and/or annual prevalence — the total number of people of a given people diagnosed with drug use disorders (harmful use age range who have used a given drug at least once in or drug dependence), based on clinical criteria as con- the past year, divided by the number of people of the tained in the Diagnostic and Statistical Manual of Mental given age range, and expressed as a percentage. Disorders (fifth edition) of the American Psychiatric Asso- ciation, or the International Classification of Diseases and paste (or coca base) — an extract of the leaves of the Related Health Problems (tenth revision) of WHO. coca bush. Purification of coca paste yields cocaine (base and hydrochloride). people who suffer from drug use disorders/people with drug use disorders — a subset of people who use drugs. Harm- “crack” cocaine — cocaine base obtained from cocaine ful use of substances and dependence are features of hydrochloride through conversion processes to make it drug use disorders. People with drug use disorders need suitable for smoking. treatment, health and social care and rehabilitation. cocaine salt — cocaine hydrochloride. harmful use of substances — defined in the International Statistical Classification of Diseases and Related Health drug use — use of controlled psychoactive substances for Problems (tenth revision) as a pattern of use that causes non-medical and non-scientific purposes, unless other- damage to physical or mental health. wise specified. dependence — defined in the International Statistical Clas- fentanyls — fentanyl and its analogues. sification of Diseases and Related Health Problems (tenth revision) as a cluster of physiological, behavioural and new psychoactive substances — substances of abuse, either cognitive phenomena that develop after repeated sub- in a pure form or a preparation, that are not controlled stance use and that typically include a strong desire to under the Single Convention on Narcotic Drugs of 1961 take the drug, difficulties in controlling its use, persisting or the 1971 Convention, but that may pose a public health in its use despite harmful consequences, a higher priority threat. In this context, the term “new” does not neces- given to drug use than to other activities and obligations, sarily refer to new inventions but to substances that have increased tolerance, and sometimes a physical withdrawal recently become available. state.

121 substance or drug use disorders — referred to in the Diag- nostic and Statistical Manual of Mental Disorders (fifth edition) as patterns of symptoms resulting from the repeated use of a substance despite experiencing prob- lems or impairment in daily life as a result of using substances. Depending on the number of symptoms iden- tified, may be mild, moderate or severe.

prevention of drug use and treatment of drug use disorders — the aim of “prevention of drug use” is to prevent or delay the initiation of drug use, as well as the transition to drug use disorders. Once a person develops a drug use disorder, treatment, care and rehabilitation are needed. WORLD DRUG REPORT 2021 REPORT DRUG WORLD

122 REGIONAL GROUPINGS 31

The World Drug Report uses a number of regional and > South America: Argentina, Bolivia (Plurinational subregional designations. These are not official designa- State of), Brazil, Chile, Colombia, Ecuador, Guyana, tions, and are defined as follows: Paraguay, Peru, Suriname, Uruguay, Venezuela

(Bolivarian Republic of) and Falkland Islands GLOSSARY AFRICA (Malvinas) > East Africa: Burundi, Comoros, Djibouti, Eritrea, ASIA Ethiopia, Kenya, Madagascar, Mauritius, Rwanda, Seychelles, Somalia, South Sudan, Uganda, United > Central Asia and Transcaucasia: Armenia, Azerbaijan, Republic of Tanzania and Mayotte Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, GROUPINGS REGIONAL Turkmenistan and Uzbekistan > North Africa: Algeria, Egypt, Libya, Morocco, Sudan and Tunisia > East and South-East Asia: Brunei Darussalam, Cambodia, China, Democratic People’s Republic of > Southern Africa: Angola, Botswana, Eswatini, Korea, Indonesia, Japan, Lao People’s Democratic Lesotho, Malawi, Mozambique, Namibia, South Republic, Malaysia, Mongolia, Myanmar, Philippines, Africa, Zambia, Zimbabwe and Reunion Republic of Korea, Singapore, Thailand, Timor-Leste, > West and Central Africa: Benin, Burkina Faso, Viet Nam, Hong Kong, China, Macao, China, and Cabo Verde, Cameroon, Central African Republic, Province of China Chad, Congo, Côte d’Ivoire, Democratic Republic of South-West Asia: Afghanistan, Iran (Islamic Republic the Congo, Equatorial Guinea, Gabon, Gambia, > of) and Pakistan Ghana, Guinea, Guinea-Bissau, Liberia, Mali, Mauri- tania, Niger, Nigeria, Sao Tome and Principe, Senegal, > Near and Middle East: Bahrain, Iraq, Israel, Jordan, Sierra Leone, Togo and Saint Helena Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, United Arab Emirates, Yemen and AMERICAS State of Palestine > Caribbean: Antigua and Barbuda, Bahamas, > South Asia: Bangladesh, Bhutan, India, Maldives, Barbados, Cuba, Dominica, Dominican Republic, Nepal and Sri Lanka Grenada, Haiti, Jamaica, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Trinidad and EUROPE Tobago, Anguilla, Aruba, Bonaire, Netherlands, British Virgin Islands, Cayman Islands, Curaçao, > Eastern Europe: Belarus, Republic of Moldova, Guadeloupe, Martinique, Montserrat, Puerto Rico, Russian Federation and Ukraine Saba, Netherlands, Sint Eustatius, Netherlands, Sint Maarten, Turks and Caicos Islands and United States > South-Eastern Europe: Albania, Bosnia and Virgin Islands Herzegovina, Bulgaria, Croatia, Montenegro, North Macedonia, Romania, Serbia, Turkey and > Central America: Belize, Costa Rica, El Salvador, Kosovo1 Guatemala, Honduras, Nicaragua and Panama > North America: Canada, Mexico, United States of America, Bermuda, Greenland and Saint-Pierre and 1 References to Kosovo shall be understood to be in the context of Miquelon Security Council resolution 1244 (1999). 123 > Western and Central Europe: Andorra, Austria, Belgium, Cyprus, Czechia, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, San Marino, Slovakia, Slovenia, Spain, Sweden, Switzerland, United Kingdom of Great Britain and Northern Ireland, Holy See, Faroe Islands and Gibraltar

OCEANIA > Australia and New Zealand: Australia and New Zealand > Polynesia: Cook Islands, Niue, Samoa, Tonga, Tuvalu, French Polynesia, Tokelau and Wallis and Futuna Islands WORLD DRUG REPORT 2021 REPORT DRUG WORLD > Melanesia: Fiji, Papua New Guinea, Solomon Islands, Vanuatu and New Caledonia > Micronesia: Kiribati, Marshall Islands, Micronesia (Federated States of), Nauru, Palau, Guam and Northern Mariana Islands

124 Vienna International Centre, PO Box 500, 1400 Vienna, Austria Tel: +(43) (1) 26060-0, Fax: +(43) (1) 26060-5866, www.unodc.org

Consisting of five separate booklets, theWorld Drug Report 2021 provides an in-depth analysis of the global drug markets and paints a comprehensive picture of the measurable effects and potential impact of the COVID-19 crisis on the world drug problem. Booklet 1 summarizes the four subsequent booklets by reviewing their key findings and highlighting their policy implications. Booklet 2 offers a projection of the impact of popu- lation growth on drug use by 2030 and gives a global overview of the supply of and demand for drugs, including their health impact and the trafficking of substances over the Internet. Booklet 3 provides an analysis of the global markets for cannabis and opioids, both in terms of supply and use, and includes an overview of the latest developments in countries with measures regulating the non-medical use of cannabis; it also discusses the overlaps between the various opioids and looks at access to pharmaceutical opioids for medical use. Booklet 4 contains the latest trends in and estimates of the markets for stimulants – cocaine, meth- amphetamine, amphetamine and “ecstasy” – both at the global level and in the most affected subregions. Booklet 5 presents an early assessment of the impact of the COVID-19 pandemic on drug markets by looking at how it has affected drug supply and demand dynamics, including in terms of health consequences and how drug service provision has adapted to the new situation in many countries; the booklet closes with a look at how the pandemic may influence long-term changes in the drug markets. The World Drug Report 2021 is aimed not only at fostering greater international cooperation to counter the impact of the world drug problem on health, governance and security, but also, with its special focus on the impact of the COVID-19 pandemic, at assisting Member States in anticipating and addressing challenges that may arise in the near future.

The accompanying statistical annex is published on the UNODC website: www.unodc.org/unodc/en/data-and-analysis/wdr2021.html

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